Risk Factor Surveys (Interview and SAQ)

Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) Evaluation

Documents and Forms

Document Name Document Type
Form 2 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

Information Collection (IC) Details

IC Title:	Risk Factor Surveys (Interview and SAQ)	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
Form and Instruction	2	Household Member Interview for Telephone Interviewing	Attachment 2b. Household Member Interview.doc		Yes	Yes	Fillable Fileable
Form and Instruction	3	Reach U.S. Study Booklet	Attachment 2c. SAQ.pdf		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 %

	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

Title	Document	Date Uploaded
Attachment 2d	Attachment 2d. Advance Letter.doc	01/26/2012

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