Information Collection

Health Exam

IC 244155 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⚠️ Notice: This information collection may be referencing outdated material.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 Health Exam	Form and Instruction
0920-22IA Att 6 LifeSatisfaction Att 6 LifeSatisfaction_10-26-2021_clean.docx	Form and Instruction
0920-22IA Att 6 LifeSatisfaction Att 6 LifeSatisfaction_10-26-2021_clean.docx	Form and Instruction

IC Title:

Health Exam

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 6 LifeSatisfaction	Att 6 LifeSatisfaction_10-26-2021_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 5,000

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	5,000	-5,000	10,000
Annual IC Time Burden (Hours)	3,750	-3,750	7,500
Annual IC Cost Burden (Dollars)	0	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.