Information Collection

Core Questionnaire

IC 186174 under ICR 201108-0920-010 · OMB 0920-0794.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 3B -- Behavioral Assessment.docx	Other-WORD
Att 3E -- Spanish Translation.doc Att 3E -- Spanish Translation	IC Document
Att 3D -- Flashcards.docx Att 3D -- Flashcards	IC Document

IC Title:

Core Questionnaire

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
Other-WORD			Att 3B -- Behavioral Assessment.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	667	667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 3E -- Spanish Translation	Att 3E -- Spanish Translation.doc	08/22/2011
Att 3D -- Flashcards	Att 3D -- Flashcards.docx	08/22/2011

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