Information Collection

Eligible Household (Completes Survey)

IC 192631 under ICR 201208-0955-012 · OMB 0955-0012.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
AttachmentD_Questionnaire_FinalRev_070110_FINAL.doc	Other-questionaire
0990-attitudestowardelectronic attachment_A_Sample Search Terms.doc 0990-attitudestowardelectronic attachment_A_Sample Search Terms	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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
Other-questionaire			AttachmentD_Questionnaire_FinalRev_070110_FINAL.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,570

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,570	2,570
Annual IC Time Burden (Hours)	857	857
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-attitudestowardelectronic attachment_A_Sample Search Terms	0990-attitudestowardelectronic attachment_A_Sample Search Terms.doc	03/22/2010

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