Information Collection

Childhood Injury and Adult Occupational Injury Survey

IC 36789 under ICR 201205-0535-001 · OMB 0535-0235.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form QID Childhood Injury and Adult Occupational Injury Survey	Form and Instruction
QID Childhhood Injury and Adult Occupational Injury Question 0235 - 2012 NIOSH CAIS questionnaire.doc	Form and Instruction

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	QID	Childhhood Injury and Adult Occupational Injury Questionnnaire	0235 - 2012 NIOSH CAIS questionnaire.doc		No		Paper Only

Line of Business: Economic Development

Subfunction: Industry Sector Income Stabilization

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26,667

Number of Respondents for Small Entity: 21,300

Affected Public: Private Sector

Private Sector: Farms

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	53,334	13,201	-110,367	150,500
Annual IC Time Burden (Hours)	8,889	-2,816	-406	12,111
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
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.