Survey screener

Health and Diet Survey

Documents and Forms

Document Name Document Type
0545 Survey Questionnaire.doc Other-Questionnaire
core questions - Health and Diet Survey.doc Other-Core questions
Health and Diet Survey survey screener.doc Other-Survey survey screener

Information Collection (IC) Details

IC Title:	Survey screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 survey screener	Health and Diet Survey survey screener.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: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	990	990
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.