Information Collection

Participant Questionnaire

IC 207190 under ICR 201306-0920-001 · OMB 0920-0982.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0982 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Participant Questionnaire	Form
Participant Questionnaire Att 5_Participant Questionnaire_8_28_2013.docx	Form

IC Title:

Participant Questionnaire

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	Participant Questionnaire	Att 5_Participant Questionnaire_8_28_2013.docx		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: 225

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	225	225
Annual IC Time Burden (Hours)	38	38
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.