Information Collection

ACASI Questionnaire English

IC 217341 under ICR 201507-0925-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 ACASI Questionnaire English	Form and Instruction
1 ACASI Questionnaire English Attach_1_ACASI_Questionnaire_English_9_2014_V_3.0.docx	Form and Instruction
Attach_5_ACASI_Questionnaire_Portuguese_10_14_V_2.0.docx ACASI Questionnaire Portuguese	IC Document

IC Title:

Agency IC Tracking Number:

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
Form and Instruction	1	ACASI Questionnaire English	Attach_1_ACASI_Questionnaire_English_9_2014_V_3.0.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 275

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	275	275
Annual IC Time Burden (Hours)	183	183
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ACASI Questionnaire Portuguese	Attach_5_ACASI_Questionnaire_Portuguese_10_14_V_2.0.docx	07/07/2015

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