Information Collection

Adult and Adolescent Questionnaire

IC 226775 under ICR 201708-0923-001 · OMB 0923-0058.

Documents and Forms

Document Name Document Type
Adult and Adolescent Questionnaire Form
Adult/Adolescent Questionnaire Att4d FieldUser AdultAdolescent Questionnaire_Final.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Adult and Adolescent Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Adult/Adolescent Questionnaire	Att4d FieldUser AdultAdolescent Questionnaire_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	131	131

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.