Information Collection

Adult Questionnaire

IC 239057 under ICR 201908-0923-002 · OMB 0923-0063.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0063 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Questionnaire	Form and Instruction
Multi-site Study Adult Questionnaire M_Att16_AdltQstnnr_20191212.docx	Form and Instruction

IC Title:

Adult 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 and Instruction	n/a	Multi-site Study Adult Questionnaire	M_Att16_AdltQstnnr_20191212.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN 09â19â0001, ââRecords of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"

FR Citation: 76 FR 4432

Number of Respondents: 2,333

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,333	2,333
Annual IC Time Burden (Hours)	1,167	1,167
Annual IC Cost Burden (Dollars)	29,139	29,139

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.