Information Collection

Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)

IC 7462 under ICR 201107-0925-002 · OMB 0925-0538.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0538 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Cycle 1 Qx Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
Form 1 Cycle 1 Survey Potential Questions Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
Form 1 Full Survey Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
Form 1 Short Survey Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)	Form
Appendix K - Cover Letters in English-FINAL.docx	Other-Cover Letter
1 Cycle 1 Qx Appendix B2 - Survey (placeholder).doc	Form and Instruction
1 Cycle 1 Survey Potential Questions Appendix B1 - List of Potential Items.pdf	Form and Instruction
1 Full Survey Appendix B2 - full survey.pdf	Form and Instruction
1 Short Survey Appendix B2 - short survey.pdf	Form
Appendix L - Letters in Spanish.docx Appendix L - Letters in Spanish	IC Document
Appendix K - Cover Letters in English.docx Appendix K - Cover Letters in English	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Cycle 1 Qx	Appendix B2 - Survey (placeholder).doc	Yes	No	Paper Only
Form and Instruction	1	Cycle 1 Survey Potential Questions	Appendix B1 - List of Potential Items.pdf	Yes	No	Paper Only
Form and Instruction	1	Full Survey	Appendix B2 - full survey.pdf	Yes	No	Paper Only
Form	1	Short Survey	Appendix B2 - short survey.pdf	Yes	No	Paper Only
Other-Cover Letter			Appendix K - Cover Letters in English-FINAL.docx	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN # 09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD,"

FR Citation: 67 FR 60743

Number of Respondents: 3,533

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 Agency Discretion
Annual Number of Responses for this IC	3,533	3,533
Annual IC Time Burden (Hours)	1,767	1,767
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix L - Letters in Spanish	Appendix L - Letters in Spanish.docx	06/27/2011
Appendix K - Cover Letters in English	Appendix K - Cover Letters in English.docx	06/27/2011

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