Information Collection

Head of household Consent

IC 244949 under ICR 202012-0920-010 · OMB 0920-1356.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1356 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Head of household Consent	Form and Instruction
Head of household consent AttachmentD_HeadOfHousehold_Consent_Form.docx	Form and Instruction

IC Title:

Head of household Consent

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Head of household consent	AttachmentD_HeadOfHousehold_Consent_Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 702

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	702	702
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	667	667

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.