Information Collection

Baseline questionnaire

IC 193096 under ICR 201006-0920-001 · OMB 0920-0859.

Documents and Forms

Document Name Document Type
Baseline questionnaire Form
Baseline Health and Exposure Questionnaire OMB_Attach3_0920-09BQ_Baseline questionnaire_29July2010.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline questionnaire	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Baseline Health and Exposure Questionnaire	OMB_Attach3_0920-09BQ_Baseline questionnaire_29July2010.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and surveillance of disease problems	FR Citation: 57 FR 62812

Number of Respondents: 40	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
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	13	13
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.