Information Collection

Behavioral Survey

IC 216377 under ICR 201504-0920-010 · OMB 0920-1080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 3a_Behavioral Survey Instrument.docx	Other-WORD
Att 3b_Behavioral Survey Screen shots.pdf	Other-Screenshots
Att 5_Behavioral Survey Instruction Card.docx Att 5 Behavioral Survey Instruction Card	IC Document

IC Title:

Behavioral Survey

Agency IC Tracking Number:

15JX

Is this a Common Form? No

IC Status: New

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
Other-WORD			Att 3a_Behavioral Survey Instrument.docx		Yes	Yes	Fillable Printable
Other-Screenshots			Att 3b_Behavioral Survey Screen shots.pdf		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

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	2,500	2,500
Annual IC Time Burden (Hours)	292	292
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 5 Behavioral Survey Instruction Card	Att 5_Behavioral Survey Instruction Card.docx	05/15/2015

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