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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.