Information Collection

Verification Questionnaire for Baseline and 6-Month Follow-up Visits (9% subsample)

IC 199171 under ICR 201204-0920-002 · OMB 0920-0925.

Documents and Forms

Document Name Document Type
Verification Questionnaire for Baseline and 6-Month Follow-up Visits (9% subsample) Form
Verification for Interview Attachment Q.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Verification Questionnaire for Baseline and 6-Month Follow-up Visits (9% subsample)	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	none	Verification for Interview	Attachment Q.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 43	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	43	43
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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