Information Collection

Health Information National Trends Survey

IC 215033 under ICR 201608-0925-002 · OMB 0925-0538.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Information National Trends Survey	Form and Instruction
1 B1- Instrument in English B1 - Instrument in English.docx	Form and Instruction
B2 - Instrument in Spanish.docx B2 Instrument in Spanish	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 and Instruction	1	B1- Instrument in English	B1 - Instrument in English.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,318

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-4,318	4,318
Annual IC Time Burden (Hours)	-2,159	2,159
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
B2 Instrument in Spanish	B2 - Instrument in Spanish.docx	02/18/2015

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