Information Collection

Quantitative Household Survey

IC 199729 under ICR 201110-0920-003 · OMB 0920-0908.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
REVISED_Attachment 4_4HouseholdSurvey_Nov 10 2011.doc	Instruction
Attch8ConsentScriptHousehold.docx Household Consent Script	IC Document

IC Title:

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
Instruction			REVISED_Attachment 4_4HouseholdSurvey_Nov 10 2011.doc		No		Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 256

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	256	256
Annual IC Time Burden (Hours)	192	192
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Household Consent Script	Attch8ConsentScriptHousehold.docx	10/06/2011

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