Information Collection

Demographic, Health and Preference Qx for FORCS

IC 190236 under ICR 201107-0925-003 · OMB 0925-0605.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Demographic, Health and Preference Qx for FORCS	Form and Instruction
6 Demographic, Health and Preference Qx Attach 7 - FORCS Demo health and Pref Questionnaire 11-0330.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Demographic, Health and Preference Qx for FORCS

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	6	Demographic, Health and Preference Qx	Attach 7 - FORCS Demo health and Pref Questionnaire 11-0330.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 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: 360

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	360	117	243
Annual IC Time Burden (Hours)	90	78	12
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.