Information Collection

Cycle 3 Qx for Health Information National Trends Survey 4 (HINTS4)

IC 181323 under ICR 201502-0925-003 · OMB 0925-0538.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0538 can be found here:

2016-08-25 - Reinstatement with change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Cycle 3 Instrument - English Cycle 3 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
Form 4 Cycle 3 Instrument - Spanish Cycle 3 Qx for Health Information National Trends Survey 4 (HINTS4)	Form and Instruction
3 Cycle 3 Instrument - English Appendix C - English Instrument.pdf	Form and Instruction
4 Cycle 3 Instrument - Spanish Appendix D - Spanish Instrument.pdf	Form and Instruction
Appendix K - Cover Letters in English.docx Appendix K - Cover Letters in English	IC Document
Appendix L - Letters in Spanish.docx Appendix L - Letters in Spanish	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Cycle 3 Qx for Health Information National Trends Survey 4 (HINTS4)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	3				No	No	Printable Only
Form and Instruction	4				No	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD,"

FR Citation: 67 FR 60743

Number of Respondents: 3,500

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-3,500	3,500
Annual IC Time Burden (Hours)	-1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix K - Cover Letters in English		06/27/2011
Appendix L - Letters in Spanish		06/27/2011

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

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