Demographic Questionnaire

Development of a Health Information Rating System (HIRS)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form Form #1 Demographic Questionnaire Form
Form #1 Demographic Questionnaire Attachment C - Demographic Questionnaire.doc Form

Information Collection (IC) Details

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:

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 %

	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

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.