Information Collection

My Air My Health Survey

IC 204124 under ICR 201106-2010-002 · OMB 2010-0042.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2010-0042 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2434ss12 My Air Survey.docx	Other-Other
2434ss12 My Air Justification.docx 2434ss12 My Air Justification	IC Document

IC Title:

My Air My Health Survey

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-Other			2434ss12 My Air Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Environmental Management

Subfunction: Environmental Monitoring and Forecasting

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 418

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 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	418	0	0	0	0	0
Annual IC Time Burden (Hours)	105	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
2434ss12 My Air Justification	2434ss12 My Air Justification.docx	08/28/2012

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