Information Collection

Student Component - Household Study Form A

IC 228816 under ICR 202108-0920-002 · OMB 0920-1039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1039 Student Component - Household Study Form A	Form
Form 0920-1039 ORCHARDS HOUSEHOLD STUDY FORM A Student Component - Household Study Form A	Form
0920-1039 ORCHARDS HOUSEHOLD STUDY FORM A Att C4a household forms all.pdf	Form
0920-1039 ORCHARDS HOUSEHOLD STUDY FORM A Att C4a household forms all.pdf	Form

IC Title:

Agency IC Tracking Number:

0920-1039

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?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1039			NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42484

Number of Respondents: 300

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
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.

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