Information Collection

Core Questionnaire - Child, Adult, & Household

IC 202214 under ICR 201401-0925-004 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 26.3 Core Questionnaire - Child, Adult, & Household	Form and Instruction
26.2 Survey CoreQuestionnaireAdult.docx	Form and Instruction
26.3 Survey CoreQuestionnaireHousehold.docx	Form and Instruction
26.1 Revised Survey CoreQuestionnaireChild_REVISED.docx	Form and Instruction
VaccinationGridCoreModule.docx VaccinationGridCoreModule	IC Document

IC Title:

Core Questionnaire - Child, Adult, & Household

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	26.3	Survey	CoreQuestionnaireHousehold.docx	Yes	Yes	Paper Only
Form and Instruction	26.2	Survey	CoreQuestionnaireAdult.docx	Yes	Yes	Paper Only
Form and Instruction	26.1 Revised	Survey	CoreQuestionnaireChild_REVISED.docx	Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,107

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,963	8,775	1,188
Annual IC Time Burden (Hours)	5,646	5,052	594
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
VaccinationGridCoreModule	VaccinationGridCoreModule.docx	11/08/2013

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