Information Collection

UAB Questionnaire

IC 236633 under ICR 201906-0920-008 · OMB 0920-1271.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
UAB Questionnaire	Form
UAB Questionnaire Attachment C. UAB Questionnaire_FINAL_OMB edits_06202019 clean (OMB)_AS 09232019_CLEAN.docx	Form
Part of C.consent.clean.190211 IRB Approved.pdf Consent	IC Document

IC Title:

UAB 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	none	UAB Questionnaire	Attachment C. UAB Questionnaire_FINAL_OMB edits_06202019 clean (OMB)_AS 09232019_CLEAN.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

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	600	600
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	725	725

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent	Part of C.consent.clean.190211 IRB Approved.pdf	10/07/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.