Information Collection

Household Screening Respondent

IC 216698 under ICR 201704-0910-005 · OMB 0910-0815.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0815 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_1_Clean.pdf	Other-Questionnaires - English
2.3_Enrollment_Survey_Spanish_REV_CLEAN_MAR2017.pdf	Other-Questionnaires - Spanish

IC Title:

Household Screening Respondent

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-Questionnaires - Spanish			2.3_Enrollment_Survey_Spanish_REV_CLEAN_MAR2017.pdf		Yes	Yes	Fillable Fileable
Other-Questionnaires - English			Attachment_1_Clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29,385

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	Previously Approved
Annual Number of Responses for this IC	9,697	9,697
Annual IC Time Burden (Hours)	1,261	1,261
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.