Information Collection

Women's Health Survey

IC 214584 under ICR 201501-0920-012 · OMB 0920-1065.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 3 Women's Health Survey (Complete).pdf	Other-WORD
Att 4_Invite and Info Sheet_rev_01-05-15_05-14-15.docx	Other-WORD
Att 1a. Johannas Law.pdf Att 1a_ Authorizing Legislation	IC Document
Att 1b. PHSA.DOC Att 1b_Authorizing Legislation	IC Document
Att 2a. 60-day FRN 2 26 2014.pdf Att 2a_ 60d Published FRN	IC Document
Att 2b. Summary of Public Comments.doc Att 2b_Summary of Public Comments	IC Document
Att 5_IRB Approval Letter.pdf Att 5_IRB Approval Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Other-WORD			Att 3 Women's Health Survey (Complete).pdf		Yes	Yes	Fillable Printable
Other-WORD			Att 4_Invite and Info Sheet_rev_01-05-15_05-14-15.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,424

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	2,424	2,424
Annual IC Time Burden (Hours)	808	808
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 1a_ Authorizing Legislation	Att 1a. Johannas Law.pdf	01/12/2015
Att 1b_Authorizing Legislation	Att 1b. PHSA.DOC	01/12/2015
Att 2a_ 60d Published FRN	Att 2a. 60-day FRN 2 26 2014.pdf	01/12/2015
Att 2b_Summary of Public Comments	Att 2b. Summary of Public Comments.doc	01/12/2015
Att 5_IRB Approval Letter	Att 5_IRB Approval Letter.pdf	01/12/2015

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