Information Collection

Demographic Survey

IC 247304 under ICR 202105-0920-002 · OMB 0920-1351.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1351 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-20PJ Demographic Survey Form and Instruction
0920-20PJ Demographic Survey Attachment I_Demographic Survey.docx Form and Instruction
0920-20PJ Demographic Survey Attachment I_Demographic Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Demographic Survey	Agency IC Tracking Number:	0920-20PJ

Is this a Common Form? No		IC Status: New

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	0920-20PJ	Demographic Survey	Attachment I_Demographic Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.