Information Collection

Reporting: Cognitive Interview Screener

IC 199196 under ICR 201109-0910-002 · OMB 0910-0706.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0706 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A Hispanic study draft questionnaire 0611.doc	Other-Survey Questionnaire

IC Title:

Reporting: Cognitive Interview Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-Survey Questionnaire			Appendix A Hispanic study draft questionnaire 0611.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72

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
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.