Information Collection

Telephone Interview

IC 198154 under ICR 201106-0920-012 · OMB 0920-0892.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0892 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form New form Telephone Interview	Form and Instruction
New form Attachment F CDI Health Interview Attachment F _ CDI Health Interview Attachment.doc	Form and Instruction
Attachment G - CDI Case Report Form.pdf Attachment G CDI Case Report Form	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
Form and Instruction	New form	Attachment F CDI Health Interview	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
	Approved	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 CDI Case Report Form	Attachment G - CDI Case Report Form.pdf	06/16/2011

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