Information Collection

Survey questionnaire

IC 220010 under ICR 201607-0920-007 · OMB 0920-1122.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1122 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey questionnaire	Form
CH STRONG survey - screenshots Att. 14 - Online Survey.pdf	Form
English Survey Att 3 - English Survey 15Jul2016.docx	Form
Spanish Survey Att. 12 - Spanish Survey 15Jul2016.docx	Form

IC Title:

Survey questionnaire

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	CH STRONG survey - screenshots	Att. 14 - Online Survey.pdf	Yes	Yes	Fillable Fileable
Form	none	English Survey	Att 3 - English Survey 15Jul2016.docx	Yes	Yes	Fillable Fileable
Form	none	Spanish Survey	Att. 12 - Spanish Survey 15Jul2016.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiological Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 6,675

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,675	6,675
Annual IC Time Burden (Hours)	2,225	2,225
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.