Information Collection

Health Survey

IC 195214 under ICR 201011-0923-001 · OMB 0923-0042.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0042 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Survey	Form
Health Survey Attachment C survey.doc	Form
Health Survey Attachment C survey 2011_10 clean.docx	Form

IC Title:

Health Survey

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	Health Survey	Attachment C survey.doc		Yes	Yes	Fillable Fileable
Form	None	Health Survey	Attachment C survey 2011_10 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47,601

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	47,601	47,601
Annual IC Time Burden (Hours)	35,701	35,701
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.