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Pilot Study
Health Information National Trends Survey V (HINTS V) (NCI)
OMB: 0925-0538
IC ID: 223114
OMB.report
HHS/NIH
OMB 0925-0538
ICR 201608-0925-002
IC 223114
( )
Documents and Forms
Document Name
Document Type
Form 2
Pilot Study
Form
2 Pilot Instrument
Appendix E - Pilot Instrument.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Pilot Study
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
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
2
Pilot Instrument
Appendix E - Pilot Instrument.pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service
FR Citation:
67 FR 60743
Number of Respondents:
533
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
533
0
533
0
0
0
Annual IC Time Burden (Hours)
267
0
267
0
0
0
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.
