Information Collection

Telephone Interview

IC 197248 under ICR 201104-0920-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment F _ CDI Health Interview Attachment.doc	Instruction
Attachment G - CDI Case Report Form.pdf Attachment G	IC Document

IC Title:

Telephone Interview

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
Instruction			Attachment F _ CDI Health Interview Attachment.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment G	Attachment G - CDI Case Report Form.pdf	03/17/2011

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