Information Collection

Interview

IC 235196 under ICR 202106-0920-005 · OMB 0920-1266.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interview	Form and Instruction
ChiCAS Interview - English 05JUN2019 Att 4e_ChiCAS Interview English_03Oct2018.docx	Form and Instruction
ChiCAS Interview - English 05JUN2019 Att 4e_ChiCAS Interview English_03Oct2018.docx	Form and Instruction
ChiCAS Interview - Spanish 05JUN2019 Att 4f_ChiCAS Interview Spanish_03Oct2018.doc	Form and Instruction
ChiCAS Interview - Spanish 05JUN2019 Att 4f_ChiCAS Interview Spanish_03Oct2018.doc	Form and Instruction
0920-1266 ChiCAS Interview - English JUN2021 Att 4g_ChiCAS Interview English.docx	Form and Instruction
0920-1266 ChiCAS Interview - English JUN2021 Att 4g_ChiCAS Interview English.docx	Form and Instruction
0920-1266 ChiCAS Interview - Spanish JUN2021 Att 4h_ChiCAS Interview Spanish.docx	Form and Instruction
0920-1266 ChiCAS Interview - Spanish JUN2021 Att 4h_ChiCAS Interview Spanish.docx	Form and Instruction

IC Title:

Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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?	Electronic Capability
Form and Instruction	NA	ChiCAS Interview - English 05JUN2019	Att 4e_ChiCAS Interview English_03Oct2018.docx	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Interview - Spanish 05JUN2019	Att 4f_ChiCAS Interview Spanish_03Oct2018.doc	NA	No	Paper Only
Form and Instruction	0920-1266	ChiCAS Interview - English JUN2021	Att 4g_ChiCAS Interview English.docx	NA	No	Paper Only
Form and Instruction	0920-1266	ChiCAS Interview - Spanish JUN2021	Att 4h_ChiCAS Interview Spanish.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	23	23
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.