Information Collection

Household Screener Instrument

IC 216263 under ICR 202203-0920-004 · OMB 0920-0314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Household Screener Instrument	Form and Instruction
NSFG Household Screener Instrument in Capilite Format ATT-H-NSFG-screener-capilite-Sep2021.docx	Form and Instruction
NSFG Household Screener Instrument in Capilite Format ATT-H-NSFG-screener-capilite-Sep2021.docx	Form and Instruction

IC Title:

Household Screener Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	n/a	NSFG Household Screener Instrument in Capilite Format	ATT-H-NSFG-screener-capilite-Sep2021.docx		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: 13,500

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	13,500	13,500
Annual IC Time Burden (Hours)	675	675
Annual IC Cost Burden (Dollars)	20,223	20,223

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.