Information Collection

Self-Query Survey

IC 207741 under ICR 201307-0915-003 · OMB 0915-0366.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0366 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Self-Query Survey Form and Instruction
1 Self-Query Survey Self-Query_Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self-Query Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	1	Self-Query Survey	Self-Query_Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	134	134
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.