Information Collection

Voluntary Survey Modules

IC 192031 under ICR 201908-0923-003 · OMB 0923-0041.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Voluntary Survey Modules	Form
Voluntary Survey Modules Attach6ApprovedSurveys (screenshots).docx	Form
Sports participation module Attach6BNewSportsParticipationMdle.docx	Form
Attach6AScoring ALSFRS final.docx ALS Functional Rating Scale	IC Document

IC Title:

Voluntary Survey Modules

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	Voluntary Survey Modules	Attach6ApprovedSurveys (screenshots).docx		Yes	Yes	Fillable Fileable
Form	none	Sports participation module	Attach6BNewSportsParticipationMdle.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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: 750

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	Previously Approved
Annual Number of Responses for this IC	750	0	750
Annual IC Time Burden (Hours)	1,063	63	1,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ALS Functional Rating Scale	Attach6AScoring ALSFRS final.docx	08/26/2019

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