Information Collection

Vital Signs Survey

IC 207398 under ICR 201303-0920-011 · OMB 0920-0956.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0956 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Vital Signs Survey	Form and Instruction
Vital Signs Survey VS_screenshots.docx	Form and Instruction
Vital Signs Survey Vital Signs Surveyv2.docx	Form and Instruction
Survey1template _VitalSignsv2.docx Survey1template _VitalSignsv2	IC Document

IC Title:

Vital Signs Survey

Agency IC Tracking Number:

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	Vital Signs Survey	VS_screenshots.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Vital Signs Survey	Vital Signs Surveyv2.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	3,000	0	0	0	0	0
Annual IC Time Burden (Hours)	351	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey1template _VitalSignsv2	Survey1template _VitalSignsv2.docx	06/11/2013

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