Information Collection

SEARCH Health Questionnaire (Youth )

IC 211580 under ICR 201705-0920-019 · OMB 0920-0904.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 4b.1_Health Questionnaire (Young Adult_ Feb 2014).pdf	Other-WORD

IC Title:

Agency IC Tracking Number:

0920-0904

Is this a Common Form? No

IC Status: Removed

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-WORD			Att 4b.1_Health Questionnaire (Young Adult_ Feb 2014).pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 710

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-710	710
Annual IC Time Burden (Hours)	-178	178
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.