Information Collection Request

Heritage Health Index 2014 Survey (HHI)

ICR 201404-3137-001 · OMB 3137-0088 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form HHI 2014 Form 1 2014 Heritage Health Index survey questionnaire Form and Instruction New Available
IMLS HHI 2014 NonRespBias Questionnaire Web 2014-09-05.docx Supplementary Document Uploaded 2014-09-08 Repair queued
IMLS HHI 2014 NonRespBias Questionnaire Paper 2014-09-05.docx Supplementary Document Uploaded 2014-09-08 Available
IMLS HHI 2014 Collection Questionnaire Web 2014-09-05.docx Supplementary Document Uploaded 2014-09-08 Available
IMLS HHI 2014 Appendices A to O 2014-09-05.docx Supplementary Document Uploaded 2014-09-08 Available
Appendices A-H 3-28-14.docx Supplementary Document Uploaded 2014-04-14 Available
HHI 2014 Contact Verification Script.docx Supplementary Document Uploaded 2014-04-14 Available
HHI 2014 NonResp BiasQuestionnaire.docx Supplementary Document Uploaded 2014-04-14 Available
IMLS HHI 2014 Supporting Statement Part B 2014-09-05.docx Supporting Statement B Uploaded 2014-09-08 Available
IMLS HHI 2014 Supporting Statement Part A 2014-09-05.docx Supporting Statement A Uploaded 2014-09-08 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
211214 2014 Heritage Health Index survey questionnaire Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
09/30/2017 36 Months From Approved
4,979 0 0
5,507 0 0
137,620 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
2014 Heritage Health Index survey questionnaire HHI 2014 Form 1 HHI 2014 Collection Questoinnaire

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 4,979 0 0 4,979 0 0
Annual Time Burden (Hours) 5,507 0 0 5,507 0 0
Annual Cost Burden (Dollars) 137,620 0 0 137,620 0 0


Reginfo record details
  No