Information Collection

Adult Questionnaire

IC 187120 under ICR 201110-0930-002 · OMB 0930-0298.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0298 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Adult Questionniar Adult Questionnaire	Form
Adult Admin Guide Cohort N.docx	Instruction
Adult Questionniar Adult Questionniare Adult Questionniare Cohort N.docx	Form
Overview of Instruments Guide.docx Overview of Instruments Guide	IC Document

IC Title:

Adult 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
Form	Adult Questionniare	Adult Questionniare	Adult Questionniare Cohort N.docx		Yes	Yes	Paper Only
Instruction			Adult Admin Guide Cohort N.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,682

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,899	-3,306	20,205
Annual IC Time Burden (Hours)	12,234	-4,536	16,770
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Overview of Instruments Guide	Overview of Instruments Guide.docx	09/29/2011

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