Health Care Utilization/Sense of Community (for adult)

Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study

Documents and Forms

Document Name Document Type
Form No number Health Care Utilization/Sense of Community (for adult) Form
No number Health Services Utilization - Sense of Community Questio Attachment 20 Health Services Utilization-Sense of Community Questionnaire for Adult.doc Form

Information Collection (IC) Details

IC Title:	Health Care Utilization/Sense of Community (for adult)	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
Form	No number	Health Services Utilization - Sense of Community Questionnaire	Attachment 20 Health Services Utilization-Sense of Community Questionnaire for Adult.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 196	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	196	196
Annual IC Time Burden (Hours)	65	65
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.