Information Collection

Student Component - Household Study Form A

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

Documents and Forms

Document Name Document Type
Form 0920-1039 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Student Component - Household Study Form A	Agency IC Tracking Number:	0920-1039

Is this a Common Form? No		IC Status: Modified

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	0920-1039	ORCHARDS HOUSEHOLD STUDY FORM A	Att C4a household forms all.pdf	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 %

	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

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.