Information Collection

Text Reponses and Demographics

IC 209616 under ICR 201312-0925-004 · OMB 0925-0700.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0700 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Text Reponses and Demographics	Form
1 Demographics Attach 5. Demographics Questions.pdf	Form
2 Text Responses Attach 2. Interactive Exhibit Display Prompts.pdf	Form

IC Title:

Text Reponses and Demographics

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	Demographics	Attach 5. Demographics Questions.pdf		Yes	Yes	Fillable Fileable
Form	2	Text Responses	Attach 2. Interactive Exhibit Display Prompts.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	114,000	114,000
Annual IC Time Burden (Hours)	1,900	1,900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.