Information Collection

Paper and Pencil Questionnaire

IC 182367 under ICR 200710-0920-005 · OMB 0920-0762.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0762 can be found here:

Documents and Forms

Document Name Document Type
A3 Paper and Pencil Questionaire.doc Other-Questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Paper and Pencil Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Questionnaire			A3 Paper and Pencil Questionaire.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 72	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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