Information Collection

Adult - Survey

IC 236787 under ICR 202009-0910-007 · OMB 0910-0880.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix G HPHC2 Online Survey Adult Consent Form_CLEAN.docx	Other-Online Survey Adult Consent Fo
Appendix K HPHC2 Online Survey Questionnaire_CLEAN_9.10.20.docx	Other-Online Survey Questionnaire
Appendix Q HPHC2 Online Survey Adult Reminder Email_CLEAN_2.20.docx	Other-Online Survey Adult Invitation

IC Title:

Adult - Survey

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Online Survey Adult Consent Form	Appendix G HPHC2 Online Survey Adult Consent Form_CLEAN.docx	Yes	Yes	Fillable Fileable Signable
Other-Online Survey Questionnaire	Appendix K HPHC2 Online Survey Questionnaire_CLEAN_9.10.20.docx	Yes	Yes	Fillable Fileable Signable
Other-Online Survey Adult Invitation Reminder Email	Appendix Q HPHC2 Online Survey Adult Reminder Email_CLEAN_2.20.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,300	3,300
Annual IC Time Burden (Hours)	1,100	1,100
Annual IC Cost Burden (Dollars)	0	0

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.