Information Collection

Focus Groups

IC 183722 under ICR 200901-0925-003 · OMB 0925-0584.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0584 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 11 Focus Groups	Form and Instruction
11 Occupation Occupation_7-04-07.doc	Form and Instruction
12 Oral Health Oral.doc	Form and Instruction
13 Personal Information Personal.doc	Form and Instruction
14 Physical Activity Physical.doc	Form and Instruction
15 Respiratory Respiratory_7-05-07.doc	Form and Instruction
16 SF12 SF12v2.doc	Form and Instruction
17 Sleep Sleep_6-29-07.doc	Form and Instruction
18 Social Cultural Sociocultural_07-04-07.doc	Form and Instruction
19 Tobacco Use Tobacco.doc	Form and Instruction
20 Weight History Weight.doc	Form and Instruction
21 Well Being Wellbeing_5-25-07.doc	Form and Instruction

IC Title:

Focus Groups

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	11	Occupation	Occupation_7-04-07.doc	Yes	Yes	Paper Only
Form and Instruction	12	Oral Health	Oral.doc	Yes	Yes	Paper Only
Form and Instruction	13	Personal Information	Personal.doc	Yes	Yes	Paper Only
Form and Instruction	14	Physical Activity	Physical.doc	Yes	Yes	Paper Only
Form and Instruction	15	Respiratory	Respiratory_7-05-07.doc	Yes	Yes	Paper Only
Form and Instruction	16	SF12	SF12v2.doc	Yes	Yes	Paper Only
Form and Instruction	17	Sleep	Sleep_6-29-07.doc	Yes	Yes	Paper Only
Form and Instruction	18	Social Cultural	Sociocultural_07-04-07.doc	Yes	Yes	Paper Only
Form and Instruction	19	Tobacco Use	Tobacco.doc	Yes	Yes	Paper Only
Form and Instruction	20	Weight History	Weight.doc	Yes	Yes	Paper Only
Form and Instruction	21	Well Being	Wellbeing_5-25-07.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 81

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	Previously Approved
Annual Number of Responses for this IC	81	81
Annual IC Time Burden (Hours)	122	122
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.