Information Collection

Caregiver Interview

IC 178551 under ICR 200702-0920-001 · OMB 0920-0741.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0741 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B 2 Caregiver Interview.doc	Other-Primary Caregiver Interview
Appendix B 2 Caregiver Interview.doc Telephone Script	IC Document

IC Title:

Caregiver Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Primary Caregiver Interview			Appendix B 2 Caregiver Interview.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 3,456

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,456	3,456
Annual IC Time Burden (Hours)	3,456	3,456
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Telephone Script	Appendix B 2 Caregiver Interview.doc	06/05/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.