Information Collection

Paper-Based Questionnaire (Pilot and Mult-site)

IC 204802 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Paper-Based Questionnaire (Pilot and Mult-site) Form
Paper-based Questionaire OMB Appendix G Household survey (paper version).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Paper-Based Questionnaire (Pilot and Mult-site)	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	none	Paper-based Questionaire	OMB Appendix G Household survey (paper version).pdf		Yes	No	Paper Only

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: 886	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	886	886
Annual IC Time Burden (Hours)	177	177
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.