Information Collection

Adult Questionnaire

IC 234095 under ICR 201811-0930-002 · OMB 0930-0357.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0357 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Adult Questinnaire Adult Questionnaire	Form and Instruction
Adult Questinnaire Adult Questinnaire 2 MAI_MRT_Adult Questinnaire_10.11.2018 - final.docx	Form and Instruction

IC Title:

Adult Questionnaire

Agency IC Tracking Number:

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	Adult Questinnaire	Adult Questinnaire	2 MAI_MRT_Adult Questinnaire_10.11.2018 - final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24,000	24,000
Annual IC Time Burden (Hours)	4,800	4,800
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.