Information Collection

Study

IC 221072 under ICR 201604-0910-007 · OMB 0910-0820.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix D - Study Questionnaire English-062316.docx	Other-Survey
Study Questionnaire Spanish-062316.docx	Other-Survey
Study Questionnaire Screenshots English-062316.docx	Other-Screenshot
Study Questionnaire Screenshots Spanish-062316.docx	Other-Screenshots

IC Title:

Study

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screenshots	Study Questionnaire Screenshots Spanish-062316.docx	Yes	Yes	Paper Only
Other-Survey	Appendix D - Study Questionnaire English-062316.docx	Yes	Yes	Fillable Fileable
Other-Screenshot	Study Questionnaire Screenshots English-062316.docx	Yes	Yes	Paper Only
Other-Survey	Study Questionnaire Spanish-062316.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	3,000	3,000
Annual IC Time Burden (Hours)	750	750
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.