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4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation
NCHS Questionnaire Design Research Laboratory
OMB: 0920-0222
IC ID: 203563
OMB.report
HHS/CDC
OMB 0920-0222
ICR 201205-0920-001
IC 203563
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:
2022-12-21 - Revision of a currently approved collection
2021-08-16 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation
Form and Instruction
Four Sets of Health Related Questions
QDRL 4 sets of health related Qs - Attachment 1-0731 2012.docx
Form and Instruction
Blood Donor History Questionnaire
QDRL OASH Blood Donor Attach 2-0731 2012.doc
Form and Instruction
QDRL OMB-10-day combo letter-0731 2012.doc
genIC Combo Letter to Dr. Schwab
IC Document
QDRL 4 sets Health Related Qs Attachment 2-0731 2012.docx
4 Sets of Questions Flyer
IC Document
QDRL OASH Blood Donor-10 day letter-0731 2012.doc
Blood Donor Letter to Dr. Schwab
IC Document
QDRL OASH Blood Donor-Attach 1-10 day letter from 1125 2011-v2.doc
Previous Blood Donor Letter to Dr. Schwab
IC Document
QDRL OASH Blood Donor Attach 3abc-0731 2012.doc
Blood Donor Flyers
IC Document
QDRL 4 sets Health Related Qs 10-day letter-0827 2012.docx
QDRL 4 sets of questions letter
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation
Agency IC Tracking Number:
IC Status:
New
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
none
Four Sets of Health Related Questions
QDRL 4 sets of health related Qs - Attachment 1-0731 2012.docx
Yes
Yes
Fillable Fileable
Form and Instruction
none
Blood Donor History Questionnaire
QDRL OASH Blood Donor Attach 2-0731 2012.doc
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
Health and Demographic Surveys Conducted in Probability Samples of the US Population
FR Citation:
49 FR 37693
Number of Respondents:
125
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
125
0
0
0
0
0
Annual IC Time Burden (Hours)
125
0
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
genIC Combo Letter to Dr. Schwab
QDRL OMB-10-day combo letter-0731 2012.doc
08/01/2012
4 Sets of Questions Flyer
QDRL 4 sets Health Related Qs Attachment 2-0731 2012.docx
08/01/2012
Blood Donor Letter to Dr. Schwab
QDRL OASH Blood Donor-10 day letter-0731 2012.doc
08/01/2012
Previous Blood Donor Letter to Dr. Schwab
QDRL OASH Blood Donor-Attach 1-10 day letter from 1125 2011-v2.doc
08/01/2012
Blood Donor Flyers
QDRL OASH Blood Donor Attach 3abc-0731 2012.doc
08/01/2012
QDRL 4 sets of questions letter
QDRL 4 sets Health Related Qs 10-day letter-0827 2012.docx
08/27/2012
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.