Information Collection

Adult - Survey

IC 236787 under ICR 201905-0910-007 · OMB 0910-0880.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0880 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix G HPHC2 Online Survey Adult Consent Form_clean.docx	Other-Online Survey Adult Consent Fo
Appendix K HPHC2 Online Survey Questionnaire_clean.docx	Other-Online Survey Questionnaire

IC Title:

Adult - Survey

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-Online Survey Adult Consent Form			Appendix G HPHC2 Online Survey Adult Consent Form_clean.docx		Yes	Yes	Fillable Fileable Signable
Other-Online Survey Questionnaire			Appendix K HPHC2 Online Survey Questionnaire_clean.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	3,000	3,000
Annual IC Time Burden (Hours)	1,000	1,000
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.