Information Collection

Survey

IC 183123 under ICR 201712-0910-003 · OMB 0910-0545.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0545 Survey Questionnaire.doc	Other-Questionnaire
core questions - Health and Diet Survey.doc	Other-Core questions
Health and Diet Survey questionnaire.doc	Other-Survey Questionnaire

IC Title:

Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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-Questionnaire	0545 Survey Questionnaire.doc	Yes	Yes	Fillable Fileable
Other-Core questions	core questions - Health and Diet Survey.doc	Yes	Yes	Fillable Fileable
Other-Survey Questionnaire	Health and Diet Survey questionnaire.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	750	750
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.