Information Collection

Individual Questionnaire

IC 234594 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⚠️ Notice: This information collection may be referencing outdated material.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 Individual Questionnaire	Form and Instruction
0920-18ANU Individual Questionnaire 5. EN Paper Questionnaire - Individual.docx	Form and Instruction
0920-18ANU Individual Questionnaire Spanish 5. ES Paper Questionnaire - Individual.docx	Form and Instruction

IC Title:

Individual 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	Individual Questionnaire	5. EN Paper Questionnaire - Individual.docx	na	No		Fillable Fileable
Form and Instruction	0920-18ANU	Individual Questionnaire Spanish	5. ES Paper Questionnaire - Individual.docx	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: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	7,250	7,250

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.