Information Collection

Reporting : Demographic Questionnaire

IC 198723 under ICR 201108-0910-003 · OMB 0910-0696.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0696 can be found here:

Documents and Forms

Document Name Document Type
Pilot total ( survey instrument) 7-13-11.doc Other-questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reporting : Demographic Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-questionnaire			Pilot total ( survey instrument) 7-13-11.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,380	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,380	1,380
Annual IC Time Burden (Hours)	110	110
Annual IC Cost Burden (Dollars)	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.