Information Collection

Eligible Respondents

IC 187314 under ICR 201206-0925-005 · OMB 0925-0552.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0552 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Questionaire Eligible Respondents	Form and Instruction
1 Questionaire Att A NDEP Natl Diab Survey Final Annotated Questionnaire 2012_forOMB.pdf	Form and Instruction

IC Title:

Eligible Respondents

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	1				Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,100	2,100	0
Annual IC Time Burden (Hours)	693	525	168
Annual IC Cost Burden (Dollars)	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.

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