Information Collection

Household Questionnaire

IC 241512 under ICR 202004-0920-015 · OMB 0920-1293.

Documents and Forms

Document Name Document Type
Household Questionnaire Form
Household Questionnaire 24APR2020 Att3b_Household Questionnaire.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Household Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	Household Questionnaire 24APR2020	Att3b_Household Questionnaire.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,680	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,680	1,680
Annual IC Time Burden (Hours)	420	420
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.