Information Collection

Health and Media Survey

IC 204661 under ICR 201210-0920-013 · OMB 0920-0967.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health and Media Survey	Form and Instruction
Attachment 6a Health and Media Survey Attachment 6a_Health and Media Survey_022613.docx	Form and Instruction
Attachment 6b Health and Media Survey Attachment 6b (rev) Health and Media Survey Screenshots.pdf	Form and Instruction
Attachment 8_Email Notification and Reminders.docx Attachment 8_Email Notification and Reminders	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
Form and Instruction	None	Attachment 6a Health and Media Survey	Attachment 6a_Health and Media Survey_022613.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Attachment 6b Health and Media Survey	Attachment 6b (rev) Health and Media Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,399

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 Agency Discretion
Annual Number of Responses for this IC	15,399	15,399
Annual IC Time Burden (Hours)	7,700	7,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 8_Email Notification and Reminders	Attachment 8_Email Notification and Reminders.docx	10/29/2012

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