Information Collection

Adult Questionnaire

IC 234695 under ICR 201908-0923-001 · OMB 0923-0061.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0061 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Questionnaire	Form
Adult Questionnaire P_Att18_PeaseAdltQstnnr_20190813 clean.docx	Form

IC Title:

Adult Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Adult Questionnaire	P_Att18_PeaseAdltQstnnr_20190813 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 367

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	367	367
Annual IC Time Burden (Hours)	184	184
Annual IC Cost Burden (Dollars)	4,584	4,584

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.