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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.