Information Collection

Individuals/Households - Households

IC 226896 under ICR 201705-0584-004 · OMB 0584-0530.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0530 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
D03 Household Survey Income Worksheet.docx	Other-Appendix D3. Household Survey
D04 Household Survey Income Worksheet-Spanish.docx	Other-Appendix D4. Household Survey
D05 Household Survey_6.15.17.docx	Other-Appendix D5. Household Survey
D06 Household Survey-Spanish_6.15.17.docx	Other-Appendix D6. Household Survey
D09 Household Survey Incentives Received Form.doc	Other-Appendix D9. Household Survey
D10 Household Survey Incentives Received Form-Spanish.doc	Other-Appendix D10. Household Survey
D13 Household Interview.docx	Other-Appendix D13. Household Interv
D14 Household Interview-Spanish.docx	Other-Appendix D14. Household Interv
D15 Household Interview Incentives Received Form.doc	Other-Appendix D15. Household Interv
D16 Household Interview Incentives Received Form-Spanish.doc	Other-Appendix D16. Household Interv
I01 Household Survey Consent Form.docx	Other-Appendix I1. Household Survey
I02 Household Survey Consent Form-Spanish.docx	Other-Appendix I2. Household Survey
T05 Household Survey Recruitment Contact Guide.docx	Other-Appendix T5. Household Survey
T06 Household Survey Recruitment Contact Guide-Spanish.docx	Other-Appendix T6. Household Survey
T07 Household Interview Recruitment Contact Guide.docx	Other-Appendix T7. Household Intervi
T08 Household Interview Recruitment Contact Guide-Spanish.docx	Other-Appendix T8. Household Intervi
D01 Household Survey Appointment Reminder Letter.docx Appendix D1. Household Survey Appointment Reminder Letter	IC Document
D02 Household Survey Appointment Reminder Letter-Spanish.docx Appendix D2. Household Survey Appointment Reminder Letter - Spanish	IC Document
D07 Household Survey Income Source Show Card.docx Appendix D7. Household Survey Income Source Show Card	IC Document
D08 Household Survey Income Source Show Card-Spanish.docx Appendix D8. Household Survey Income Source Show Card - Spanish	IC Document
D11 Household Interview Appointment Reminder Letter.pdf Appendix D11. Household Interview Appointment Reminder Letter	IC Document
D12 Household Interview Appointment Reminder Letter-Spanish.pdf Appendix D12. Household Interview Appointment Reminder Letter - Spanish	IC Document
T01 Household Survey Recruitment Letter.docx Appendix T1. Household Survey Recruitment Letter	IC Document
T02 Household Survey Recruitment Letter-Spanish.docx Appendix T2. Household Survey Recruitment Letter - Spanish	IC Document
T03 Household Survey Brochure.docx Appendix T3. Household Survey Brochure	IC Document
T04 Household Survey Brochure-Spanish.docx Appendix T4. Household Survey Brochure - Spanish	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individuals/Households - Households

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Appendix D3. Household Survey Income Worksheet	D03 Household Survey Income Worksheet.docx	No		Paper Only
Other-Appendix D4. Household Survey Income Worksheet - Spanish	D04 Household Survey Income Worksheet-Spanish.docx	No		Paper Only
Other-Appendix D5. Household Survey	D05 Household Survey_6.15.17.docx	Yes	Yes	Fillable Fileable
Other-Appendix D6. Household Survey - Spanish	D06 Household Survey-Spanish_6.15.17.docx	Yes	Yes	Fillable Fileable
Other-Appendix D9. Household Survey Incentives Received Form	D09 Household Survey Incentives Received Form.doc	No		Paper Only
Other-Appendix D10. Household Survey Incentives Received Form - Spanish	D10 Household Survey Incentives Received Form-Spanish.doc	No		Paper Only
Other-Appendix D13. Household Interview	D13 Household Interview.docx	No		Paper Only
Other-Appendix D14. Household Interview - Spanish	D14 Household Interview-Spanish.docx	No		Paper Only
Other-Appendix D15. Household Interview Incentives Received Form	D15 Household Interview Incentives Received Form.doc	No		Paper Only
Other-Appendix D16. Household Interview Incentives Received Form - Spanish	D16 Household Interview Incentives Received Form-Spanish.doc	No		Paper Only
Other-Appendix I1. Household Survey Consent Form	I01 Household Survey Consent Form.docx	No		Paper Only
Other-Appendix I2. Household Survey Consent Form - Spanish	I02 Household Survey Consent Form-Spanish.docx	No		Paper Only
Other-Appendix T5. Household Survey Recruitment Contact Guide	T05 Household Survey Recruitment Contact Guide.docx	No		Paper Only
Other-Appendix T6. Household Survey Recruitment Contact Guide - Spanish	T06 Household Survey Recruitment Contact Guide-Spanish.docx	No		Paper Only
Other-Appendix T7. Household Interview Recruitment Contact Guide	T07 Household Interview Recruitment Contact Guide.docx	No		Paper Only
Other-Appendix T8. Household Interview Recruitment Contact Guide - Spanish	T08 Household Interview Recruitment Contact Guide-Spanish.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: FNS-8 USDA/FNS Studies and Reports

FR Citation: 56 FR 19078

Number of Respondents: 4,827

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	43,614	43,614
Annual IC Time Burden (Hours)	8,110	8,110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix D1. Household Survey Appointment Reminder Letter	D01 Household Survey Appointment Reminder Letter.docx	05/17/2017
Appendix D2. Household Survey Appointment Reminder Letter - Spanish	D02 Household Survey Appointment Reminder Letter-Spanish.docx	05/17/2017
Appendix D7. Household Survey Income Source Show Card	D07 Household Survey Income Source Show Card.docx	05/17/2017
Appendix D8. Household Survey Income Source Show Card - Spanish	D08 Household Survey Income Source Show Card-Spanish.docx	05/17/2017
Appendix D11. Household Interview Appointment Reminder Letter	D11 Household Interview Appointment Reminder Letter.pdf	05/17/2017
Appendix D12. Household Interview Appointment Reminder Letter - Spanish	D12 Household Interview Appointment Reminder Letter-Spanish.pdf	05/17/2017
Appendix T1. Household Survey Recruitment Letter	T01 Household Survey Recruitment Letter.docx	05/18/2017
Appendix T2. Household Survey Recruitment Letter - Spanish	T02 Household Survey Recruitment Letter-Spanish.docx	05/18/2017
Appendix T3. Household Survey Brochure	T03 Household Survey Brochure.docx	05/18/2017
Appendix T4. Household Survey Brochure - Spanish	T04 Household Survey Brochure-Spanish.docx	05/18/2017

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