Information Collection

Behavioral Survey

IC 216377 under ICR 202011-0920-013 · OMB 0920-1080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Behavioral Survey	Form and Instruction
Att 3a_Behavioral Survey Instrument.docx	Other-WORD document to facilitate re
Att 3a_Behavioral Survey Instrument.docx	Other-WORD document to facilitate re
Behavioral Survey (screenshots) Att 3b_Behavioral Survey Screen shots.pdf	Form and Instruction
Behavioral Survey (screenshots) Att 3b_Behavioral Survey Screen shots.pdf	Form and Instruction
Att 5 Behavioral Survey Instruction Card.docx Att 5 Behavioral Survey Instruction Card	IC Document
Att 5 Behavioral Survey Instruction Card.docx Att 5 Behavioral Survey Instruction Card	IC Document

IC Title:

Behavioral Survey

Agency IC Tracking Number:

0920-1080

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	n/a	Behavioral Survey (screenshots)	Att 3b_Behavioral Survey Screen shots.pdf		Yes	Yes	Fillable Fileable
Other-WORD document to facilitate review of survey content			Att 3a_Behavioral Survey Instrument.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 83 FR 6591

Number of Respondents: 2,700

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	2,700	200	2,500
Annual IC Time Burden (Hours)	315	23	292
Annual IC Cost Burden (Dollars)	8,100	8,100	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 5 Behavioral Survey Instruction Card	Att 5 Behavioral Survey Instruction Card.docx	08/09/2018

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