Information Collection

Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)

IC 7462 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⚠️ Notice: This information collection may be referencing outdated material.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 1 Cycle 1 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
1 Cycle 1 Qx Appendix B2 - Survey (placeholder).doc	Form and Instruction
1 Cycle 1 Survey Potential Questions Appendix B1 - List of Potential Items.pdf	Form and Instruction
1 Appendix B2: Full Survey Appendix B2 - full survey.pdf	Form and Instruction
1 Appendix B2 Short Survey Appendix B2 - short survey.pdf	Form and Instruction
Appendix L - Letters in Spanish.docx Appendix L - Letters in Spanish	IC Document
Appendix K - Cover Letters in English.docx Appendix K - Cover Letters in English	IC Document
Appendix K - Cover Letters in English-FINAL.docx Appendix K - Cover Letters in English-Final	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Cycle 1 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Cycle 1 Qx	Appendix B2 - Survey (placeholder).doc	Yes	No	Paper Only
Form and Instruction	1	Cycle 1 Survey Potential Questions	Appendix B1 - List of Potential Items.pdf	Yes	No	Paper Only
Form and Instruction	1	Appendix B2: Full Survey	Appendix B2 - full survey.pdf	Yes	No	Paper Only
Form and Instruction	1	Appendix B2 Short Survey	Appendix B2 - short survey.pdf	Yes	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN # 09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD,"

FR Citation: 67 FR 60743

Number of Respondents: 3,533

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	3,533	3,533
Annual IC Time Burden (Hours)	1,767	1,767
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix L - Letters in Spanish	Appendix L - Letters in Spanish.docx	06/27/2011
Appendix K - Cover Letters in English	Appendix K - Cover Letters in English.docx	06/27/2011
Appendix K - Cover Letters in English-Final	Appendix K - Cover Letters in English-FINAL.docx	09/30/2011

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