Information Collection

Interview

IC 202477 under ICR 201305-0930-002 · OMB 0930-0334.

Documents and Forms

Document Name Document Type
Form Attachment A quest Interview Form and Instruction
Attachment A quest Attachment A questionnaire PDF 2 - Attachment A questionnaire.pdf Form and Instruction
Attachment T.pdf Comments IC Document
PDF 1 - Attachments K, M, B, C, D.pdf Attachments K, M, B, C, D IC Document
PDF 3 - Attachment F.pdf Attachment F IC Document
PDF 4 - Attachments G, O, S.pdf Attachments G, O, S IC Document
PDF 5 - Attachment P.pdf Attachment P IC Document
PDF 6 - Attachments N, J, Q.pdf Attachments N, J, Q IC Document
PDF 7 - Attachments H, I.pdf Attachments H, I IC Document
PDF 8 - Attachment L.pdf Attachment L IC Document
PDF 9 - Attachments E, R.pdf Attachments E, R IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	Attachment A questionnaire	Attachment A questionnaire	PDF 2 - Attachment A questionnaire.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,000	0	2,000
Annual IC Time Burden (Hours)	2,000	-500	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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