Information Collection

Main Questionnaire

IC 245433 under ICR 202101-0920-015 · OMB 0920-1327.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20QJ Main Questionnaire	Form and Instruction
0920-20QJ Web Questionnaire Developer Logic Attachment 3a - Web questionnaire specifications.docx	Form and Instruction
0920-20QJ Web Questionnaire Developer Logic Attachment 3a - Web questionnaire specifications.docx	Form and Instruction
0920-20QJ Self-Administered Hardcopy Questionnaire Attachment 3b_Self administered hardcopy questionnaire.pdf	Form and Instruction
0920-20QJ Self-Administered Hardcopy Questionnaire Attachment 3b_Self administered hardcopy questionnaire.pdf	Form and Instruction
Attachment 9_Web questionnaire screenshots.pdf Main Questionnaire Screenshots	IC Document
Attachment 9_Web questionnaire screenshots.pdf Main Questionnaire Screenshots	IC Document

IC Title:

Main Questionnaire

Agency IC Tracking Number:

0920-20QJ

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	0920-20QJ	Web Questionnaire Developer Logic	Attachment 3a - Web questionnaire specifications.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QJ	Self-Administered Hardcopy Questionnaire	Attachment 3b_Self administered hardcopy questionnaire.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,650

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,650	2,650
Annual IC Time Burden (Hours)	1,325	1,325
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Main Questionnaire Screenshots	Attachment 9_Web questionnaire screenshots.pdf	01/26/2021

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