Information Collection

Child Questionnaire - Long Form

IC 239058 under ICR 202007-0923-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Child Questionnaire - Long Form	Form and Instruction
Child questionnaire - long form M_Att15_ ChldQstnnr_LongForm_20200714__clean.docx	Form and Instruction

IC Title:

Child Questionnaire - Long Form

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 and Instruction	none	Child questionnaire - long form	M_Att15_ ChldQstnnr_LongForm_20200714__clean.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: 560

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	Previously Approved
Annual Number of Responses for this IC	560	560
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	6,994	6,994

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.