Information Collection

ACBS Consent and Survey - adult

IC 224743 under ICR 201612-0920-004 · OMB 0920-1204.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1204 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ACBS Consent and Survey - adult	Form
ACBS Consent and Survey - adult Att5e ACBS Adlt Cnsnt and Srvy.docx	Form

IC Title:

ACBS Consent and Survey - adult

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	ACBS Consent and Survey - adult	Att5e ACBS Adlt Cnsnt and Srvy.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 19,954

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	19,954	19,954
Annual IC Time Burden (Hours)	3,326	3,326
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.