Information Collection

Demographic & Health Questionnaire for FEAST

IC 190241 under ICR 201107-0925-003 · OMB 0925-0605.

Documents and Forms

Document Name Document Type
Form 12 Demographic & Health Questionnaire for FEAST Form and Instruction
12 Demographic & Health Questionnaire Attach 12 - FEAST health-pref quex 11-0330.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Demographic & Health Questionnaire for FEAST	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	12	Demographic & Health Questionnaire	Attach 12 - FEAST health-pref quex 11-0330.docx		Yes	Yes	Fillable Fileable

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: 33	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	33	-47	80
Annual IC Time Burden (Hours)	6	-5	11
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.