Information Collection

Instrument 12b: HPOG 2.0 National Evaluation Intermediate Follow-up COVID-19 Cohort Short-term Survey – Critical Items Only

IC 249732 under ICR 202112-0970-002 · OMB 0970-0462.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0462 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 12b_COVID-19_CohortShortTermSurvey_Critical Items_Revised Intro_12-3-21.docx	Other-Survey
Instrument 12b_COVID-19_CohortShortTermSurvey_Critical Items_Revised 12-9-21.docx	Other-Survey

IC Title:

Instrument 12b: HPOG 2.0 National Evaluation Intermediate Follow-up COVID-19 Cohort Short-term Survey â Critical Items Only

Agency IC Tracking Number:

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
Other-Survey			Instrument 12b_COVID-19_CohortShortTermSurvey_Critical Items_Revised 12-9-21.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 518

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	172	172
Annual IC Time Burden (Hours)	57	57
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.