Information Collection

Follow Up Questionnaire

IC 247989 under ICR 202106-0920-005 · OMB 0920-1266.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1266 Follow Up Questionnaire	Form and Instruction
0920-1266 ChiCAS Follow Up Questionnaire - English JUN2021 Att 4e_ChiCAS Follow Up Questionnaire English.docx	Form and Instruction
0920-1266 ChiCAS Follow Up Questionnaire - English JUN2021 Att 4e_ChiCAS Follow Up Questionnaire English.docx	Form and Instruction
0920-1266 ChiCAS Interview - Spanish JUN2021 Att 4f_ChiCAS Follow Up Questionnaire Spanish.docx	Form and Instruction
0920-1266 ChiCAS Interview - Spanish JUN2021 Att 4f_ChiCAS Follow Up Questionnaire Spanish.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	0920-1266	ChiCAS Follow Up Questionnaire - English JUN2021	Att 4e_ChiCAS Follow Up Questionnaire English.docx	NA	No		Paper Only
Form and Instruction	0920-1266	ChiCAS Interview - Spanish JUN2021	Att 4f_ChiCAS Follow Up Questionnaire 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: 70

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	53	53
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.