Information Collection

Text Responses and Demographics

IC 209616 under ICR 201403-0925-011 · OMB 0925-0700.

Documents and Forms

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

IC Title:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 228,000

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
Annual Number of Responses for this IC	228,000	228,000
Annual IC Time Burden (Hours)	19,000	19,000
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.