Information Collection

Demographic Questionnaire

IC 235949 under ICR 201903-0990-003 · OMB 0990-0470.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Document_2_Demographic_Questionnaire_10_21_2019_clean.docx	Other-Questionnaire

IC Title:

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
Other-Questionnaire			Document_2_Demographic_Questionnaire_10_21_2019_clean.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 96

Number of Respondents for Small Entity: 96

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	96	96
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	479	479

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.