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Survey questionnaire
Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being
OMB: 0920-1122
IC ID: 220010
OMB.report
HHS/CDC
OMB 0920-1122
ICR 201607-0920-007
IC 220010
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1122 can be found here:
2018-03-14 - Reinstatement with change of a previously approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
6,675
0
0
0
0
6,675
Annual IC Time Burden (Hours)
2,225
0
0
0
0
2,225
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.