Information Collection

Interview

IC 195358 under ICR 201107-0930-002 · OMB 0930-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment B Interview	Form and Instruction
Attachment B Attachment B PDF 2 - Attachment B.pdf	Form and Instruction
PDF 5 - Attachment L.pdf Attachment L	IC Document
PDF 6 - Attachment M,N,O,P.pdf Attachment M,N,O,P	IC Document
PDF 9 - Attachment S .pdf Attachment S	IC Document

IC Title:

Interview

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	Attachment B	Attachment B	PDF 2 - Attachment B.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 67,500

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	67,500	-2,000	69,500
Annual IC Time Burden (Hours)	67,500	-2,000	69,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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