Household Forms

National Immunization Survey Evaluation Study

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.