Information Collection

Family Core Questionnaire

IC 214112 under ICR 201504-0920-008 · OMB 0920-0214.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0214 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Family Core Questionnaire	Form and Instruction
2015 Family Core Questionnaire Attachment 3a - Family Questionnaire with LOI.pdf	Form and Instruction

IC Title:

Family Core Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	None	2015 Family Core Questionnaire	Attachment 3a - Family Questionnaire with LOI.pdf	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	45,000	45,000
Annual IC Time Burden (Hours)	17,250	17,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.