Information Collection

COVID-2019 Supplemental Questionnaire

IC 243826 under ICR 202111-0920-018 · OMB 0920-0134.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0134 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0134 COVID-2019 Supplemental Questionnaire	Form and Instruction
0920-0134 Supplemental COVID-2019 Questionnaire Attachment B Supplemental COVID-2019 Questionnaire 9.23.2020 clean.docx	Form and Instruction
0920-0134 Supplemental COVID-2019 Questionnaire Attachment B Supplemental COVID-2019 Questionnaire 9.23.2020 clean.docx	Form and Instruction

IC Title:

COVID-2019 Supplemental Questionnaire

Agency IC Tracking Number:

0920-0134-20SL

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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	0920-0134	Supplemental COVID-2019 Questionnaire	Attachment B Supplemental COVID-2019 Questionnaire 9.23.2020 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,300

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	Previously Approved
Annual Number of Responses for this IC	2,300	2,300
Annual IC Time Burden (Hours)	192	192
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.