Information Collection

Household Forms

IC 188379 under ICR 200903-0607-001 · OMB 0607-0954.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0954 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 7317-110S Household Forms	Form
Attachment B 7317-100A OMB 04_23_2009.pdf	Other-Director's Advance Letter for
Attachment C 7317-100B OMB 04_23_2009.pdf	Other-Director's Advance Letter for
Attachment D 7317-ALB OMB 04_23_2009.doc	Other-Advance Letter Informational B
Attachment E 7317-IRL OMB 4_23_2009.doc	Other-Informational Refusal Letter
Attachment I 7317-100A(S) OMB 04_23_2009.doc	Other-Director's Advance Letter for
Attachment J 7317-100B(S) OMB 04_23_2009.doc	Other-Director's Advance Letter for
7317-IB Information Collection Instrument Items Booklet Attachment F 7317-IB OMB 06_03_2009.rtf	Form
7317-IBS Information Collection Instrument Items Booklet - Spanis Attachment G 7317-IBS OMB 06_03_2009.rtf	Form
7317-PPQ Immunization Survey Paper Questionnaire Attachment H 7317-PPQ OMB 06_03_2009.doc	Form
7317-110E Permission to Contact Immunization Provider - English Attachment K 7317-110E OMB 06_03_2009.pdf	Form
7317-110S Permission to Contact Immunization Provider - Spanish Attachment L 7317-110S OMB 06_03_2009.pdf	Form

IC Title:

Household Forms

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	7317-110S	Permission to Contact Immunization Provider - Spanish	Attachment L 7317-110S OMB 06_03_2009.pdf	No		Paper Only
Form	7317-110E	Permission to Contact Immunization Provider - English	Attachment K 7317-110E OMB 06_03_2009.pdf	No		Paper Only
Form	7317-IB	Information Collection Instrument Items Booklet	Attachment F 7317-IB OMB 06_03_2009.rtf	Yes	Yes	Fillable Fileable
Form	7317-PPQ	Immunization Survey Paper Questionnaire	Attachment H 7317-PPQ OMB 06_03_2009.doc	No		Paper Only
Form	7317-IBS	Information Collection Instrument Items Booklet - Spanish	Attachment G 7317-IBS OMB 06_03_2009.rtf	Yes	Yes	Fillable Fileable
Other-Director's Advance Letter for Households - Alternative Sampling Frame - Spanish			Attachment J 7317-100B(S) OMB 04_23_2009.doc	No		Paper Only
Other-Advance Letter Informational Brochure			Attachment D 7317-ALB OMB 04_23_2009.doc	No		Paper Only
Other-Director's Advance Letter for Households ? ACS Sample			Attachment B 7317-100A OMB 04_23_2009.pdf	No		Paper Only
Other-Director's Advance Letter for Households ? Alternative Sampling Frame			Attachment C 7317-100B OMB 04_23_2009.pdf	No		Paper Only
Other-Informational Refusal Letter			Attachment E 7317-IRL OMB 4_23_2009.doc	No		Paper Only
Other-Director's Advance Letter for Households - ACS Sample - Spanish			Attachment I 7317-100A(S) OMB 04_23_2009.doc	No		Paper Only

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,307

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 44 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,307	1,307
Annual IC Time Burden (Hours)	616	616
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.