Information Collection

Web-Based Questionnaire (Pilot and Multi-site)

IC 204801 under ICR 201211-0920-008 · OMB 0920-0960.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0960 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Web-Based Questionnaire (Pilot and Multi-site)	Form
Web-based Questionaire OMB Appendix H Household survey (web version).docx	Form

IC Title:

Web-Based Questionnaire (Pilot and Multi-site)

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	none	Web-based Questionaire	OMB Appendix H Household survey (web version).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 1,329

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	1,329	1,329
Annual IC Time Burden (Hours)	266	266
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.