Information Collection

Voluntary Survey Modules

IC 192031 under ICR 201606-0923-001 · OMB 0923-0041.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Voluntary Survey Modules	Form
Voluntary ALS Survey Modules Attach_6-Approved Surveys (screenshots)-with OMB box.docx	Form
Attach_6A-Scoring ALSFRS final.docx ALS Functional Rating Scale	IC Document

IC Title:

Voluntary Survey Modules

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Voluntary ALS Survey Modules	Attach_6-Approved Surveys (screenshots)-with OMB box.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 750

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	Previously Approved
Annual Number of Responses for this IC	750	-11,250	12,000
Annual IC Time Burden (Hours)	1,000	0	1,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ALS Functional Rating Scale	Attach_6A-Scoring ALSFRS final.docx	06/22/2016

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