Information Collection

Household Representative Questionnaire

IC 234590 under ICR 201812-0920-004 · OMB 0920-1254.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1254 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-18ANU Household Representative Questionnaire	Form and Instruction
0920-18ANU Household Representative Questionnaire 4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf	Form and Instruction

IC Title:

Household Representative 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	0920-18ANU	Household Representative Questionnaire	4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 2,720

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	2,720	2,720
Annual IC Time Burden (Hours)	454	454
Annual IC Cost Burden (Dollars)	3,292	3,292

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.