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

Health Information National Trends Survey 4 (HINTS 4) (NCI)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 4 Cycle 4 Qx for Health Information National Trends Survey 4 (HINTS4) Form and Instruction
4 List of Potential Questions for Cycle 4 Qx Appendix B1 - List of Potential Items.pdf Form and Instruction
2 English Version of Instrument for Cycle 4 Appendix B - Instrument English.docx Form and Instruction
3 Spanish Version of Instrument for Cycle 4 Appendix C - Instrument Spanish.docx 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
Appendix D - Cover Versions.docx Cover Versions IC Document
Appendix E - Shading Example.docx Shadin IC Document

Information Collection (IC) Details

IC Title:	Cycle 4 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	List of Potential Questions for Cycle 4 Qx	Appendix B1 - List of Potential Items.pdf	Yes	No	Paper Only
Form and Instruction	2	English Version of Instrument for Cycle 4	Appendix B - Instrument English.docx	No		Printable Only
Form and Instruction	3	Spanish Version of Instrument for Cycle 4	Appendix C - Instrument Spanish.docx	No		Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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

Title	Document	Date Uploaded
Appendix K - Cover Letters in English	Appendix K - Cover Letters in English.docx	06/27/2011
Appendix L - Letters in Spanish	Appendix L - Letters in Spanish.docx	06/27/2011
Cover Versions	Appendix D - Cover Versions.docx	07/01/2014
Shadin	Appendix E - Shading Example.docx	07/01/2014

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