Information Collection

Survey - Incarcerated Respondents

IC 226225 under ICR 201703-0920-015 · OMB 0920-1206.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1206 can be found here:

Documents and Forms

Document Name Document Type
Survey - Incarcerated Respondents Form
Survey Attachment E - Survey Instrument.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey - Incarcerated Respondents	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	none	Survey	Attachment E - Survey Instrument.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 105	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	105	105
Annual IC Time Burden (Hours)	131	131
Annual IC Cost Burden (Dollars)	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.