Information Collection

Household Component - Household Study Form B (Day 0, 7, and 14)

IC 248916 under ICR 202108-0920-002 · OMB 0920-1039.

Documents and Forms

Document Name Document Type
Form 0920-1039 Household Component - Household Study Form B (Day 0, 7, and 14) Form
0920-1039 ORCHARDS HOUSEHOLD STUDY FORM B Att C4a household forms all.pdf Form
0920-1039 ORCHARDS HOUSEHOLD STUDY FORM B Att C4a household forms all.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Household Component - Household Study Form B (Day 0, 7, and 14)	Agency IC Tracking Number:	0920-1039

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	0920-1039	ORCHARDS HOUSEHOLD STUDY FORM B	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: 720	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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,440	1,200	240
Annual IC Time Burden (Hours)	120	100	20
Annual IC Cost Burden (Dollars)	0	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.