Information Collection

Life Experiences Survey

IC 183868 under ICR 200802-0920-009 · OMB 0920-0788.

Documents and Forms

Document Name Document Type
Form No number Life Experiences Survey Form
No number Life Experiences Survey Attachment 25 Life Experiences Survey for adults.pdf Form
Attachment 25 Life Experiences Survey for adults OMB Cover page.doc Life Experiences Survey - Coverpage IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Life Experiences Survey	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	Life Experiences Survey	Attachment 25 Life Experiences Survey for adults.pdf		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
Life Experiences Survey - Coverpage	Attachment 25 Life Experiences Survey for adults OMB Cover page.doc	12/19/2007

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