Information Collection

Follow Up Questionnaire

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Follow Up Questionnaire	Agency IC Tracking Number:

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	0920-1266	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 %

	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

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.