Information Collection

General Population

IC 191539 under ICR 201006-0925-001 · OMB 0925-0618.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 General Population	Form
1 survey Attachment C_HIP_Survey_8-4-10.doc	Form
2 survey Attachment D_Letters_Scripts_Email_8-4-10.doc	Form
Attachment E_KN_CPS Comparison .pdf Attachment E_KN_CPS Comparison	IC Document
Attachment F_GeoDiversity of Panel.pdf Attachment F_GeoDiversity of Panel	IC Document

IC Title:

General Population

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	survey	Attachment C_HIP_Survey_8-4-10.doc		Yes	Yes	Paper Only
Form	2	survey	Attachment D_Letters_Scripts_Email_8-4-10.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD

FR Citation: 60 FR 4277

Number of Respondents: 3,250

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	3,250	3,250
Annual IC Time Burden (Hours)	1,073	1,073
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E_KN_CPS Comparison	Attachment E_KN_CPS Comparison .pdf	05/19/2010
Attachment F_GeoDiversity of Panel	Attachment F_GeoDiversity of Panel.pdf	05/21/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.