Information Collection

2017 Census Test - Self Response

IC 224066 under ICR 201609-0607-002 · OMB 0607-0996.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DG-1D 2017 Census Test - Self Response	Form
dg_16_l1_es_20160901.pdf	Other-Questionnaire Cover Letter
dg_16_l2_es_20160928.pdf	Other-Questionnaire Cover Letter
dg_16_l3_20160901.pdf	Other-Questionnaire Cover Letter
dg_16_l3_es_20160928.pdf	Other-Questionnaire Cover Letter
dg_16_l4_20160901.pdf	Other-Questionnaire Cover Letter
dg_16_l4_es_20160928.pdf	Other-Questionnaire Cover Letter
dg_17_l1_20160927.pdf	Other-Questionnaire Cover Letter
dg_17_l1_es_20160928.pdf	Other-Questionnaire Cover Letter
dg9_c_20160825.pdf	Other-Postcard
dg_9_c_es_20160908.pdf	Other-Postcard
dg9_p_20160908.pdf	Other-Postcard
dg_9_p_es_20160825.pdf	Other-Postcard
dg9_20160908.pdf	Other-Postcard
dg_9_es_20160825.pdf	Other-Postcard
dg_17_cqa_20160928.pdf	Other-Information Insert
dg_5_es_20160818.pdf	Other-Envelope
dg_6a_1_in_es_20160901.pdf	Other-Envelope
dg_6a_in_es_20160818.pdf	Other-Envelope
dg_6b_in_es_20160818.pdf	Other-Envelope
dg_8a_es_20160927.pdf	Other-Envelope
dg_16_l1_20161003.pdf	Other-Questionnaire Cover Letter
dg_16_l2_20161003.pdf	Other-Questionnaire Cover Letter
dg_17i_es_20161003.pdf	Other-Information Insert
2017 CT ISR Baseline Specification 10242016.docx survey.census.gov	Other-Specification: Internet Instru
2017 CT Internet Spec-Help Text-Appendix B 10242016.docx survey.census.gov	Other-Specification: Interent Help T
2017 CT ISR CQA Specification 10242016.docx survey.census.gov	Other-Specification: CQA Internet In
DG-1D English paper questionnaire DG-1D_092016.pdf survey.census.gov	Form
DG-1D(E/S) English/Spanish paper questionnaire DG-1D(ES)_092016.pdf survey.census.gov	Form
2017 CT Panel Design Matrix.docx 2017 Census Test Contact Strategy	IC Document
2017 Census Test - Index of Forms_20161017 - national sample only.docx 2017 Census Test- Index of Forms	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2017 Census Test - Self Response

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	DG-1D	English paper questionnaire	DG-1D_092016.pdf	survey.census.gov	Yes	Yes	Fillable Fileable
Form	DG-1D(E/S)	English/Spanish paper questionnaire	DG-1D(ES)_092016.pdf	survey.census.gov	Yes	Yes	Fillable Fileable
Other-Questionnaire Cover Letter			dg_16_l1_es_20160901.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l2_es_20160928.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l3_20160901.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l3_es_20160928.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l4_20160901.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l4_es_20160928.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_17_l1_20160927.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_17_l1_es_20160928.pdf		No		Paper Only
Other-Postcard			dg9_c_20160825.pdf		No		Paper Only
Other-Postcard			dg_9_c_es_20160908.pdf		No		Paper Only
Other-Postcard			dg9_p_20160908.pdf		No		Paper Only
Other-Postcard			dg_9_p_es_20160825.pdf		No		Paper Only
Other-Postcard			dg9_20160908.pdf		No		Paper Only
Other-Postcard			dg_9_es_20160825.pdf		No		Paper Only
Other-Information Insert			dg_17_cqa_20160928.pdf		No		Paper Only
Other-Envelope			dg_5_es_20160818.pdf		No		Paper Only
Other-Envelope			dg_6a_1_in_es_20160901.pdf		No		Paper Only
Other-Envelope			dg_6a_in_es_20160818.pdf		No		Paper Only
Other-Envelope			dg_6b_in_es_20160818.pdf		No		Paper Only
Other-Envelope			dg_8a_es_20160927.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l1_20161003.pdf		No		Paper Only
Other-Questionnaire Cover Letter			dg_16_l2_20161003.pdf		No		Paper Only
Other-Information Insert			dg_17i_es_20161003.pdf		No		Paper Only
Other-Specification: Internet Instrument			2017 CT ISR Baseline Specification 10242016.docx	survey.census.gov	Yes	Yes	Fillable Fileable
Other-Specification: Interent Help Text			2017 CT Internet Spec-Help Text-Appendix B 10242016.docx	survey.census.gov	Yes	Yes	Fillable Fileable
Other-Specification: CQA Internet Instrument			2017 CT ISR CQA Specification 10242016.docx	survey.census.gov	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36,000	36,000
Annual IC Time Burden (Hours)	6,000	6,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2017 Census Test Contact Strategy	2017 CT Panel Design Matrix.docx	10/24/2016
2017 Census Test- Index of Forms	2017 Census Test - Index of Forms_20161017 - national sample only.docx	10/24/2016

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