Adult Questionnaire

National Health Interview Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0214 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0214 Adult Questionnaire Form and Instruction
0920-0214 Adult Questionnaire Att 9b - 2021 NHIS Sample Adult Questionnaire.pdf Form and Instruction
0920-0214 Adult Questionnaire Att 9b - 2021 NHIS Sample Adult Questionnaire.pdf Form and Instruction
Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf Additional COVID Questions IC Document
Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf Additional COVID Questions IC Document

Information Collection (IC) Details

IC Title:	Adult Questionnaire	Agency IC Tracking Number:	0920-0214

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	0920-0214	Adult Questionnaire	Att 9b - 2021 NHIS Sample Adult Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	24,000	24,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Additional COVID Questions	Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf	02/05/2021

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