Information Collection

Reporting: Survey

IC 199201 under ICR 201206-0910-013 · OMB 0910-0706.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A Hispanic study draft questionnaire 0611.doc	Other-Survey Questionnaire
0910-0706 final instrument English.pdf	Other-english screen shots
0910-0706 final instrument Spanish.pdf	Other-spanish screen shots

IC Title:

Reporting: Survey

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey Questionnaire	Yes	Yes	Fillable Printable
Other-english screen shots	Yes	No	Printable Only
Other-spanish screen shots	Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

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	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	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.

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