Information Collection

General Population

IC 186436 under ICR 201203-0990-002 · OMB 0990-0335.

Documents and Forms

Document Name Document Type
0990-0335_Attachment E-1_General Pop Questionnaire.doc Other-SURVEY
0990-0335Attachment E-2_Physician Questionnaire.doc Other-QUESTIONNAIRE
0990-0335_Attachment E-3_Spanish Gen_Pop Questionnaire.DOC Other-QUESTIONNAIRE
0990-0335_Attachment H_InterviewScripts.doc Other-TELEPHONE INTERVIEW
0990-0335 GPRA2010_Attachment A.docx 0990-0335 GPRA2010_Attachment A IC Document
0990-0335_Attachment B_Public Health Service Act.docx 0990-0335_Attachment B_Public Health Service Act IC Document
0990-0335_Attachment D-1_Crosswalk of Revisions_General Population.doc 0990-0335_Attachment D-1_Crosswalk of Revisions_General Population IC Document
0990-0355_Attachment D-2_Crosswalk of Revisions_physician population.doc 0990-0355_Attachment D-2_Crosswalk of Revisions_physician population IC Document
0990-0335_Attachment G_PilotTestReport.doc 0990-0335_Attachment G_PilotTestReport IC Document
0990-0335_Attachment I_researchQuestions_Analysis.doc 0990-0335_Attachment I_researchQuestions_Analysis IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	General Population	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SURVEY	0990-0335_Attachment E-1_General Pop Questionnaire.doc	No	No	Paper Only
Other-QUESTIONNAIRE	0990-0335Attachment E-2_Physician Questionnaire.doc	No	No	Paper Only
Other-QUESTIONNAIRE	0990-0335_Attachment E-3_Spanish Gen_Pop Questionnaire.DOC	No	No	Paper Only
Other-TELEPHONE INTERVIEW	0990-0335_Attachment H_InterviewScripts.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,159	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,159	-941	4,100
Annual IC Time Burden (Hours)	790	-167	957
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
0990-0335 GPRA2010_Attachment A	0990-0335 GPRA2010_Attachment A.docx	03/28/2012
0990-0335_Attachment B_Public Health Service Act	0990-0335_Attachment B_Public Health Service Act.docx	03/28/2012
0990-0335_Attachment D-1_Crosswalk of Revisions_General Population	0990-0335_Attachment D-1_Crosswalk of Revisions_General Population.doc	03/28/2012
0990-0355_Attachment D-2_Crosswalk of Revisions_physician population	0990-0355_Attachment D-2_Crosswalk of Revisions_physician population.doc	03/28/2012
0990-0335_Attachment G_PilotTestReport	0990-0335_Attachment G_PilotTestReport.doc	03/28/2012
0990-0335_Attachment I_researchQuestions_Analysis	0990-0335_Attachment I_researchQuestions_Analysis.doc	03/28/2012

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