Information Collection

Health Survey

IC 195214 under ICR 201202-0923-002 · OMB 0923-0042.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Survey Health Survey	Form
Health Survey Attachment C Marine Health Survey April 2011.docx	Form
Attachment D prenotice and invite ltr USMC 2_11 clean.docx Att D - Invitation Letter	IC Document
Attachment F email invite 2_11 clean.doc Att F - Email Invitation	IC Document
Attachment G postcard 2_11 clean.doc Att G - Postcard Reminder/Thank you	IC Document
Attachment H email reminder 2_11 clean.doc Att H - Email Reminder/Thank you	IC Document
Attachment I reminder letter 2_11 clean.doc Att I - Reminder Letter	IC Document
Attachment J email reminder 2_11 clean.doc AttJ - Email Reminder	IC Document
Attachment K telephone reminder 2_11 clean.doc Att K - Telephone Reminder	IC Document
Attachment L Consent for Health Study participnats April 2011.doc Att L - Participant Consent	IC Document
Attachment M Consent for registrants April 2011 redline.doc Att M - Registrant Consent	IC Document
Attachment E Letters of invitation from ATSDR April 2011.doc Attachment E Letters of invitation from ATSDR April 2011	IC Document

IC Title:

Health Survey

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	none				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47,601

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	47,601	47,601
Annual IC Time Burden (Hours)	35,701	35,701
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D - Invitation Letter		04/14/2011
Att F - Email Invitation		04/14/2011
Att G - Postcard Reminder/Thank you		04/14/2011
Att H - Email Reminder/Thank you		04/14/2011
Att I - Reminder Letter		04/14/2011
AttJ - Email Reminder		04/14/2011
Att K - Telephone Reminder		04/14/2011
Att L - Participant Consent		04/14/2011
Att M - Registrant Consent		04/14/2011
Attachment E Letters of invitation from ATSDR April 2011		04/25/2011

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

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