Information Collection

#10 Sub-study "Health Information National Trends Survey 4 (HINTS 4) Pilot Test "

IC 196228 under ICR 201008-0925-003 · OMB 0925-0589.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Document Name Document Type
Form 1 #10 Sub-study "Health Information National Trends Survey 4 (HINTS 4) Pilot Test " Form and Instruction
1 Pilot Test Questionnaire and Debriefing Questionnaire #10 HINTS Pilot_Attach B_E.docx Form and Instruction
#10 Justif Memo HINTS Pilot & Attach A_C_D_F.doc #10 Justif Memo HINTS Pilot & Attach A_C_D_F IC Document
#10_HINTS Pilot Gen IC form.doc #10_HINTS Pilot Gen IC form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	#10 Sub-study "Health Information National Trends Survey 4 (HINTS 4) Pilot Test "	Agency IC Tracking Number:

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 and Instruction	1	Pilot Test Questionnaire and Debriefing Questionnaire	#10 HINTS Pilot_Attach B_E.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"	FR Citation: 67 FR 60743

Number of Respondents: 320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	320	0	0	0	0	0
Annual IC Time Burden (Hours)	153	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
#10 Justif Memo HINTS Pilot & Attach A_C_D_F	#10 Justif Memo HINTS Pilot & Attach A_C_D_F.doc	02/02/2011
#10_HINTS Pilot Gen IC form	#10_HINTS Pilot Gen IC form.doc	02/02/2011

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