Information Collection

Vaccine Question Pretesting Survey for Household Pulse Survey

IC 244878 under ICR 201909-0607-002 · OMB 0607-0725.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0725 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Vaccine Question Pretesting Survey for Household Pulse Survey	Form and Instruction
1 Vaccine Questionnaire Enclosure1_VaccineQuestionnaire.docx	Form and Instruction
Vaccine Questions Cog Testing OMB Memo.docx OMB memo	IC Document
Enclosure2_InvitationEmails.docx Invitation Emails	IC Document

IC Title:

Vaccine Question Pretesting Survey for Household Pulse Survey

Agency IC Tracking Number:

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	1	Vaccine Questionnaire	Enclosure1_VaccineQuestionnaire.docx		No		Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

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	150	150
Annual IC Time Burden (Hours)	263	263
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB memo	Vaccine Questions Cog Testing OMB Memo.docx	12/11/2020
Invitation Emails	Enclosure2_InvitationEmails.docx	12/11/2020

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