Information Collection

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

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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
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 %

table that charts list of burden
	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

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.