Information Collection

Field Feasibility Test Decedent Proxy Interview

IC 225821 under ICR 201702-0920-008 · OMB 0920-1176.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Field Feasibility Test Decedent Proxy Interview	Form and Instruction
Suggested Scripts and Data Collection Forms for Decedent Att 3d_Decedent Proxy Forms_170209.docx	Form and Instruction

IC Title:

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 and Instruction	N/A	Suggested Scripts and Data Collection Forms for Decedent Proxy Interviews	Att 3d_Decedent Proxy Forms_170209.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167

FR Citation: 49 FR 37693

Number of Respondents: 44

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44	44
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	348	348

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.