Information Collection

IIE-Informant Interview Deaths - Eng

IC 212135 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 IIE-Informant Interview Deaths - Eng	Form and Instruction
1 IIE Informant Interview Deaths IIE-Informant interview_Eng-01-15-2014.pdf	Form and Instruction
IIS-Informant interview_Spanish-01-15-2015.pdf IIS Informant Interview Deaths - Span	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	IIE Informant Interview Deaths	IIE-Informant interview_Eng-01-15-2014.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 154

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	154	154
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IIS Informant Interview Deaths - Span	IIS-Informant interview_Spanish-01-15-2015.pdf	06/27/2014

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