Information Collection

COVID-2019 Supplemental Questionnaire

IC 243826 under ICR 202203-0920-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	COVID-2019 Supplemental Questionnaire	Agency IC Tracking Number:	0920-0134-20SL

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 %

	Program Change Due to Agency Discretion	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

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.