Information Collection

Participants Survey

IC 194189 under ICR 201309-0930-001 · OMB 0930-0288.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0288 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Participant Form_E Participants Survey	Form and Instruction
Participant Form_E Participant Form_English Attachment 2-Participant Form_English_052313.doc	Form and Instruction
Participant Form_S Participant Form_Spanish Attachment 3-Participant Form_Spanish_052313.doc	Form and Instruction
Attachment 7-Invitation to Participate E-mail_052313.doc Invitation to Participate E-mail	IC Document

IC Title:

Participants Survey

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	Participant Form_English	Participant Form_English	Attachment 2-Participant Form_English_052313.doc		Yes	Yes	Fillable Printable
Form and Instruction	Participant Form_Spanish	Participant Form_Spanish	Attachment 3-Participant Form_Spanish_052313.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,500	-7,500	12,000
Annual IC Time Burden (Hours)	374	-622	996
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation to Participate E-mail	Attachment 7-Invitation to Participate E-mail_052313.doc	08/20/2013

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