Information Collection

Paper and Pencil Questionnaire

IC 182367 under ICR 200909-0920-011 · OMB 0920-0762.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0762 can be found here:

Documents and Forms

Document Name Document Type
0762_Att3b.Paper and Pencil Survey_081709.doc Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Paper and Pencil Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			0762_Att3b.Paper and Pencil Survey_081709.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 144	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	Previously Approved
Annual Number of Responses for this IC	144	72	72
Annual IC Time Burden (Hours)	36	24	12
Annual IC Cost Burden (Dollars)	0	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.