Information Collection

Health Survey Form

IC 187794 under ICR 200901-0923-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attach C survey Qs.doc	Other-Survey

IC Title:

Health Survey Form

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-Survey			Attach C survey Qs.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Certifying Interpreting Physicial File 09-20-0001

FR Citation: 57 FR 62814

Number of Respondents: 77,349

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	77,349	77,349
Annual IC Time Burden (Hours)	58,012	58,012
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.