Information Collection

Adult Control Subjects Telephone Interview

IC 210430 under ICR 201406-0920-019 · OMB 0920-1013.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1013 Adult Control Subjects Telephone Interview	Form and Instruction
0920-1013 Attachment F_Adult Interview Form CLEAN VERSION Rev Attachment F_Adult Interview Form CLEAN VERSION 6_6_14.docx	Form and Instruction
Rev Attachment F_Adult Interview Form 6_6_14.docx Rev Attachment F_Adult Interview Form 6_6_14	IC Document
Attachment F_CA CDI Spanish Adult_ Patient Interview Form_07.16.2014.doc Attachment F_CA CDI Spanish Adult_ Patient Interview Form_07.16.2014	IC Document

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	0920-1013	Attachment F_Adult Interview Form CLEAN VERSION	Rev Attachment F_Adult Interview Form CLEAN VERSION 6_6_14.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 71

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	Previously Approved
Annual Number of Responses for this IC	71	71
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Rev Attachment F_Adult Interview Form 6_6_14	Rev Attachment F_Adult Interview Form 6_6_14.docx	06/30/2014
Attachment F_CA CDI Spanish Adult_ Patient Interview Form_07.16.2014	Attachment F_CA CDI Spanish Adult_ Patient Interview Form_07.16.2014.doc	07/17/2014

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