Information Collection

PATH/Baseline- Adults Household Screener

IC 203755 under ICR 201307-0925-001 · OMB 0925-0664.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0664 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 PATH/Baseline- Adults Household Screener	Form and Instruction
1 Household Screener 3a - English. PATH Wave 1 Household Screener 7.5 2013-06-10.pdf	Form and Instruction
3a. Spanish. PATH Wave 1 Household Screener 7.5 2013-06-10.pdf 3a	IC Document

IC Title:

PATH/Baseline- Adults Household Screener

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	1	Household Screener	3a - English. PATH Wave 1 Household Screener 7.5 2013-06-10.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: NIH Privacy Act System of Records 09-25-0200 Clinical, Basic Population-based research studies of NIH, HHS/NIH/OD

FR Citation: 67 FR 60741

Number of Respondents: 104,725

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	104,725	3,742	100,983
Annual IC Time Burden (Hours)	24,436	-4,176	28,612
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
3a	3a. Spanish. PATH Wave 1 Household Screener 7.5 2013-06-10.pdf	06/28/2013

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