Information Collection

Lifestyle Questionnaire for Patients or Next-of-Kin (CEERCC)

IC 187788 under ICR 200901-0925-004 · OMB 0925-0599.

Documents and Forms

Document Name Document Type
Form 1 Lifestyle Questionnaire for Patients or Next-of-Kin (CEERCC) Form
1 Lifestyle Questionnaire Attach 6_Qnaire_w.burden.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Lifestyle Questionnaire for Patients or Next-of-Kin (CEERCC)	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	1	Lifestyle Questionnaire	Attach 6_Qnaire_w.burden.docx		No	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 440	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	440	440
Annual IC Time Burden (Hours)	293	293
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.