Information Collection

Final Survey Phone Mode

IC 228509 under ICR 201709-0920-009 · OMB 0920-1220.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-17HO Final Survey Phone Mode	Form and Instruction
0920-17HO Att B-12. Final Survey_CATI_9 26 17 Att B-12. Final Survey_CATI_9 26 17.docx	Form and Instruction
Att B-3. Falls Calendar & Log.docx Att B-3. Falls Calendar & Log	IC Document
Att B-4. Cover Letter for Monthly & Diary - Mail.docx Att B-4. Cover Letter for Monthly & Diary - Mail	IC Document
Att B-5. Cover Letter for Monthly & Diary - Email.docx Att B-5. Cover Letter for Monthly & Diary - Email	IC Document
Att B-6. Proxy Survey Protocol.docx Att B-6. Proxy Survey Protocol	IC Document
Att A-11 Research Determination.pdf Att A-11 Research Determination	IC Document
Att A-9. IRB Protocol.doc Att A-9. IRB Protocol	IC Document

IC Title:

Agency IC Tracking Number:

0920-17HO

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-17HO	Att B-12. Final Survey_CATI_9 26 17	Att B-12. Final Survey_CATI_9 26 17.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 57 FR 252

Number of Respondents: 380

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	380	380
Annual IC Time Burden (Hours)	190	190
Annual IC Cost Burden (Dollars)	4,247	4,247

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att B-3. Falls Calendar & Log	Att B-3. Falls Calendar & Log.docx	09/28/2017
Att B-4. Cover Letter for Monthly & Diary - Mail	Att B-4. Cover Letter for Monthly & Diary - Mail.docx	09/28/2017
Att B-5. Cover Letter for Monthly & Diary - Email	Att B-5. Cover Letter for Monthly & Diary - Email.docx	09/28/2017
Att B-6. Proxy Survey Protocol	Att B-6. Proxy Survey Protocol.docx	09/28/2017
Att A-11 Research Determination	Att A-11 Research Determination.pdf	09/28/2017
Att A-9. IRB Protocol	Att A-9. IRB Protocol.doc	09/28/2017

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