Child Record Check--Line 5

National Health Interview Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0214 can be found here:

Documents and Forms

Document Name Document Type
Form 3d Child Record Check--Line 5 Form and Instruction
3d Child Record Check--Immunization History Questionnaire Attachment 3d Child Record Check (5 minutes).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Child Record Check--Line 5	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3d	Child Record Check--Immunization History Questionnaire	Attachment 3d Child Record Check (5 minutes).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 2,120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,120	-7,280	9,400
Annual IC Time Burden (Hours)	177	-450	627
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.