Poison Help General Population Survey

Documents and Forms

Document Name Document Type
Form 1 Poison Help General Population Survey Form
1 Appendix B - General Population Survey.docx Appendix B - General Population Survey.docx Form
2 Appendix C - General Population Survey Screener.docx Appendix C - General Population Survey Screener.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Poison Help General Population Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	1	Appendix B - General Population Survey.docx	Appendix B - General Population Survey.docx		No		Paper Only
Form	2	Appendix C - General Population Survey Screener.docx	Appendix C - General Population Survey Screener.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,600	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	4,600	4,600
Annual IC Time Burden (Hours)	374	374
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.