Survey screener

Health and Diet Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0545 can be found here:

Documents and Forms

Document Name Document Type
0545 Survey Questionnaire.doc Other-Questionnaire
core questions - Health and Diet Survey.doc Other-Core questions
Health and Diet Survey survey screener.doc Other-Survey survey screener

Information Collection (IC) Details

IC Title:	Survey screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Core questions	core questions - Health and Diet Survey.doc	Yes	Yes	Fillable Fileable
Other-Questionnaire	0545 Survey Questionnaire.doc	Yes	Yes	Fillable Fileable
Other-Survey survey screener	Health and Diet Survey survey screener.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	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	Previously Approved
Annual Number of Responses for this IC	30,000	28,800	1,200
Annual IC Time Burden (Hours)	990	726	264
Annual IC Cost Burden (Dollars)	0	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.