Information Collection

Covid-19 Impact Survey

IC 244367 under ICR 202011-0920-014 · OMB 0920-1171.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1171 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-20BF Covid-19 Impact Survey Form and Instruction
0920-20BF C.3_COV-IMP Survey_11-12 ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx Form and Instruction
0920-20BF C.3_COV-IMP COVER sheet for Survey ITEM #6.5 Appendix C.3_COV-IMP COVER sheet for Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Covid-19 Impact Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	0920-20BF	C.3_COV-IMP Survey_11-12	ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx		No		Paper Only
Form and Instruction	0920-20BF	C.3_COV-IMP COVER sheet for Survey	ITEM #6.5 Appendix C.3_COV-IMP COVER sheet for Survey.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 81 FR 9200

Number of Respondents: 1,330	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,330	1,330
Annual IC Time Burden (Hours)	554	554
Annual IC Cost Burden (Dollars)	14,252	14,252

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.