Information Collection

Adult-Proxy Survey

IC 223030 under ICR 201608-0920-010 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult-Proxy Survey	Form
Adult-Proxy Survey - English E-3 Adult-Proxy Survey-English 08082016.docx	Form
Adult- Proxy Survey - Spanish E-8 Adult-Proxy Survey-Spanish 08082016.docx	Form

IC Title:

Adult-Proxy 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?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Adult-Proxy Survey - English	E-3 Adult-Proxy Survey-English 08082016.docx		Yes	No	Fillable Printable
Form	none	Adult- Proxy Survey - Spanish	E-8 Adult-Proxy Survey-Spanish 08082016.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 2,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	875	875
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.