Information Collection

Adult Questionnaire

IC 229171 under ICR 202111-0920-001 · OMB 0920-0214.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0214 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-22IA Adult Questionnaire	Form and Instruction
0920-22IA Att 9b - 2022NHISSampleAdult Att 9b - 2022NHISSampleAdultQuestionnaire2.pdf	Form and Instruction
0920-22IA Att 9b - 2022NHISSampleAdult Att 9b - 2022NHISSampleAdultQuestionnaire2.pdf	Form and Instruction
Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf Additional COVID Questions	IC Document
Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf Additional COVID Questions	IC Document

IC Title:

Adult Questionnaire

Agency IC Tracking Number:

0920-22IA

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 and Instruction	0920-22IA	Att 9b - 2022NHISSampleAdult	Att 9b - 2022NHISSampleAdultQuestionnaire2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,000	0	30,000
Annual IC Time Burden (Hours)	22,000	-2,000	24,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Additional COVID Questions	Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf	02/05/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.