Information Collection

Survey Quick Health Data online

IC 202747 under ICR 201106-0990-001 · OMB 0990-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0379 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0379_QHDO Survey Screen Shots (with skip logic notation 6-4-12).docx	Other-form
0990-0379 Fast track form QHDO 6 4 12.docx 0990-0379 Fast track form QHDO 6 4 12	IC Document

IC Title:

Survey Quick Health Data online

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
Other-form			0990-0379_QHDO Survey Screen Shots (with skip logic notation 6-4-12).docx		Yes	No	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: 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	500	0	0	0	0	0
Annual IC Time Burden (Hours)	42	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
0990-0379 Fast track form QHDO 6 4 12	0990-0379 Fast track form QHDO 6 4 12.docx	06/13/2012

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