Information Collection

4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation

IC 203563 under ICR 201205-0920-001 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Four Sets of Health Related Questions 4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation	Form and Instruction
Blood Donor History Questionnaire 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

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:

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	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

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 %

table that charts list of burden
	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

table that charts IC Documents
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.