Information Collection

FIT Questionnaire

IC 205257 under ICR 201310-0920-003 · OMB 0920-0963.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att_H(english).FIT_questionnaire_screens.pdf	Other-WORD
Att_H(spanish).FIT_questionnaire_screens.pdf	Other-WORD
Att F. FIT protocol instructions.docx Att F	IC Document

IC Title:

FIT Questionnaire

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
Other-WORD					Yes	Yes	Fillable Printable
Other-WORD					Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att F		12/10/2012

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

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