Information Collection

Risk Factor Surveys (Interview and SAQ)

IC 184630 under ICR 201202-0920-001 · OMB 0920-0805.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Household Member Interview for Telephone Interviewing Risk Factor Surveys (Interview and SAQ)	Form and Instruction
Form 3 Reach U.S. Study Booklet Risk Factor Surveys (Interview and SAQ)	Form and Instruction
2 Household Member Interview for Telephone Interviewing Attachment 2b. Household Member Interview.doc	Form and Instruction
3 Reach U.S. Study Booklet Attachment 2c. SAQ.pdf	Form and Instruction
Attachment 2d. Advance Letter.doc Attachment 2d	IC Document

IC Title:

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 and Instruction	2				Yes	Yes	Fillable Fileable
Form and Instruction	3				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34,900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	34,900	8,800	26,100
Annual IC Time Burden (Hours)	8,725	2,200	6,525
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 2d		01/26/2012

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

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