Information Collection

Adult and Child Disability Questions

IC 209941 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⚠️ Notice: This information collection may be referencing outdated material.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
Adult and Child Disability Questions	Form and Instruction
Screening Script 0920-0222 Attach 3 - Screening script 0106 2014.docx	Form and Instruction
Adult Disability Questions 0920-0222 Attachment 1a - Adult Disability Questions 0106 2014.doc	Form
Child Disability Questions 0920-0222 Attachment 1b - Child Disability Questions 0106 2014.docx	Form
0920-0222 QDRL Adult Child Disabilty 10-day letter 0106 2014 (nonhighlighted).docx Letter to Dr. Schwab	IC Document
0920-0222 Attach 2a-f Advertisements & Flyers.docx Att 2 - Advertisements	IC Document

IC Title:

Adult and Child Disability Questions

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Screening Script	0920-0222 Attach 3 - Screening script 0106 2014.docx	No	No	Fillable Printable
Form	none	Adult Disability Questions	0920-0222 Attachment 1a - Adult Disability Questions 0106 2014.doc	No	No	Fillable Printable
Form	none	Child Disability Questions	0920-0222 Attachment 1b - Child Disability Questions 0106 2014.docx	No	No	Fillable Printable

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: 100

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	100	0	0	0	0	0
Annual IC Time Burden (Hours)	100	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
Letter to Dr. Schwab	0920-0222 QDRL Adult Child Disabilty 10-day letter 0106 2014 (nonhighlighted).docx	01/08/2014
Att 2 - Advertisements	0920-0222 Attach 2a-f Advertisements & Flyers.docx	01/08/2014

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