Information Collection

Text Responses and Demographics

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Text Responses and Demographics	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 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 %

	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

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.