Information Collection

Covid-19 Impact Survey

IC 244367 under ICR 202012-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 0920-21BF Covid-19 Impact Survey	Form and Instruction
0920-21BF COVID-19 Impact Study, 2020 ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx	Form and Instruction
0920-21BF Survey Cover Sheet ITEM #6.5 Appendix C.3_COV-IMP COVER sheet for Survey.docx	Form and Instruction
OMB0920_1171 NonSubstantive Change Request Memo_11-13-2020.docx Change Request Memo	IC Document
OMB 0920-1171 Expedited Review request_.docx Expedited Review Request	IC Document

IC Title:

Covid-19 Impact Survey

Agency IC Tracking Number:

0920-21BF

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	0920-21BF	COVID-19 Impact Study, 2020	ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-21BF	Survey Cover Sheet	ITEM #6.5 Appendix C.3_COV-IMP COVER sheet for Survey.docx		Yes	Yes	Fillable Fileable

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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
Change Request Memo	OMB0920_1171 NonSubstantive Change Request Memo_11-13-2020.docx	12/08/2020
Expedited Review Request	OMB 0920-1171 Expedited Review request_.docx	12/08/2020

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