Information Collection

Cycle 4 Qx for Health Information National Trends Survey 4 (HINTS4)

IC 181324 under ICR 201306-0925-007 · OMB 0925-0538.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0538 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Cycle 4 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
4 List of Potential Questions for Cycle 4 Qx Appendix B1 - List of Potential Items.pdf	Form and Instruction
Appendix K - Cover Letters in English.docx Appendix K - Cover Letters in English	IC Document
Appendix L - Letters in Spanish.docx Appendix L - Letters in Spanish	IC Document

IC Title:

Cycle 4 Qx for Health Information National Trends Survey 4 (HINTS4)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	4	List of Potential Questions for Cycle 4 Qx	Appendix B1 - List of Potential Items.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix K - Cover Letters in English	Appendix K - Cover Letters in English.docx	06/27/2011
Appendix L - Letters in Spanish	Appendix L - Letters in Spanish.docx	06/27/2011

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