Information Collection

Behavioral Survey

IC 216377 under ICR 201808-0920-004 · OMB 0920-1080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1080 Behavioral Survey	Form and Instruction
Att 3a Behavioral Survey Instrument_19_13_2018_final.docx	Other-WORD
0920-1080 Behavioral Survey Instrument Att 3b Behavioral Survey Screen shots_9_13_2018_final.pdf	Form and Instruction
Att 5 Behavioral Survey Instruction Card.docx Att 5 Behavioral Survey Instruction Card	IC Document

IC Title:

Behavioral Survey

Agency IC Tracking Number:

0920-1080

Is this a Common Form? No

IC Status: Modified

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	0920-1080	Behavioral Survey Instrument	Att 3b Behavioral Survey Screen shots_9_13_2018_final.pdf		Yes	Yes	Fillable Fileable
Other-WORD			Att 3a Behavioral Survey Instrument_19_13_2018_final.docx		No		Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	292	292
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 5 Behavioral Survey Instruction Card	Att 5 Behavioral Survey Instruction Card.docx	08/09/2018

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