Information Collection

Baseline questionnaire

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Baseline questionnaire	Form
Baseline Health and Exposure Questionnaire OMB_Attach3_0920-09BQ_Baseline questionnaire_29July2010.doc	Form

IC Title:

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	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 %

table that charts list of burden
	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

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.