Information Collection

Survey

IC 237213 under ICR 201907-0920-009 · OMB 0920-1277.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1277 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-19VJ Survey	Form and Instruction
0920-19VJ CSAW Questionnaire Att 3 - CSAW Questionnaire.docx	Form and Instruction

IC Title:

Survey

Agency IC Tracking Number:

0920-19VJ

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	0920-19VJ	CSAW Questionnaire	Att 3 - CSAW Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 627

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	627	627
Annual IC Time Burden (Hours)	314	314
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.