Information Collection

Illness Impact Questionnaire

IC 246583 under ICR 202102-0920-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20QS Illness Impact Questionnaire	Form and Instruction
0920-20QS Illness Impact Questionnaire 17_Illness Impact Questionnaire.pdf	Form and Instruction
0920-20QS Illness Impact Questionnaire 17_Illness Impact Questionnaire.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-20QS

Is this a Common Form? Yes

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	0920-20QS	Illness Impact Questionnaire	17_Illness Impact Questionnaire.pdf		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 69

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	69	69
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

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.