Information Collection

Follow-Up Survey

IC 222242 under ICR 201606-0920-018 · OMB 0920-1139.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Follow-Up Survey	Form and Instruction
First Follow-Up Survey - English Att. D1 -- First Follow-Up Survey.docx	Form and Instruction
First Follow-Up Survey - Spanish Att. D1 -- First Follow-up Survey ESP.docx	Form and Instruction
Follow-Up Survey - English Att. D2 -- Follow-up Survey.docx	Form and Instruction
Follow-Up Survey - Spanish Att. D2 -- Follow-up Survey ESP.docx	Form and Instruction

IC Title:

Follow-Up Survey

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?	Electronic Capability
Form and Instruction	NA	First Follow-Up Survey - English	Att. D1 -- First Follow-Up Survey.docx	NA	No	Paper Only
Form and Instruction	NA	First Follow-Up Survey - Spanish	Att. D1 -- First Follow-up Survey ESP.docx	NA	No	Paper Only
Form and Instruction	NA	Follow-Up Survey - English	Att. D2 -- Follow-up Survey.docx	NA	No	Paper Only
Form and Instruction	NA	Follow-Up Survey - Spanish	Att. D2 -- Follow-up Survey ESP.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problemsl

FR Citation: 57 FR 62812

Number of Respondents: 250

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	3,000	3,000
Annual IC Time Burden (Hours)	50	50
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.