Information Collection

Surnivor Follow-Up Questionnaire - Pilot

IC 221122 under ICR 201603-0920-013 · OMB 0920-1149.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Surnivor Follow-Up Questionnaire - Pilot	Form
Survivor Questionnaire (Initial Study Visit and Follow-u Att5_SurvivorQuestionnaire 20150518 clean.docx	Form

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	NA	Survivor Questionnaire (Initial Study Visit and Follow-up) Male/Female - Pilot	Att5_SurvivorQuestionnaire 20150518 clean.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
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.