Information Collection

One-on-One Surveys

IC 194003 under ICR 201011-0920-007 · OMB 0920-0869.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3a One-on-One Surveys	Form and Instruction
0920-09CJ_att3b_One-on-One Interview Guide OADS.06162010.docx	Other-Interview Guide
3a Screening Tool 0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx	Form and Instruction
3c Screener for One-on-One Surveys 0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.OADS.docx	Form and Instruction
Survey (attachment 3d) 0920-0869.Phase 2 Quantitative Survey.11012010.docx	Form
0920-0869_Local IRB approval.Phase 2 One-on-One Survey.docx IRB Approval	IC Document

IC Title:

One-on-One Surveys

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3a	Screening Tool	0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx	Yes	Yes	Fillable Fileable
Other-Interview Guide			0920-09CJ_att3b_One-on-One Interview Guide OADS.06162010.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3c	Screener for One-on-One Surveys	0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.OADS.docx	Yes	Yes	Fillable Fileable
Form	none	Survey (attachment 3d)	0920-0869.Phase 2 Quantitative Survey.11012010.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IRB Approval	0920-0869_Local IRB approval.Phase 2 One-on-One Survey.docx	11/08/2010

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