Information Collection

Verification form

IC 188703 under ICR 200904-0920-005 · OMB 0920-0314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Verification form	Form and Instruction
4 Screening Verification Questionnaire NSFG 2009 ATTACH J--Verify.doc	Form and Instruction

IC Title:

Verification form

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 and Instruction	4	Screening Verification Questionnaire	NSFG 2009 ATTACH J--Verify.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health Demographic Surveys conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 1,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	117	117
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.