Information Collection

Core Questionnaire

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.