Information Collection

Demographic Questionnaire

IC 204407 under ICR 201210-0935-001 · OMB 0935-0207.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0207 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Demographic Questionnaire	Form
Form #1 Demographic Questionnaire Attachment C - Demographic Questionnaire.doc	Form

IC Title:

Demographic Questionnaire

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	Form #1	Demographic Questionnaire	Attachment C - Demographic Questionnaire.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

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
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	4	4
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.