Information Collection

Household Representative Questionnaire

IC 234590 under ICR 202204-0920-005 · OMB 0920-1254.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-18ANU Household Representative Questionnaire	Form and Instruction
0920-18ANU Household Representative Questionnaire 4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf	Form and Instruction
0920-18ANU Household Representative Questionnaire 4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf	Form and Instruction
0920-1254 Household Representative Questionnaire - Data Collection Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	Form and Instruction
0920-1254 Household Representative Questionnaire - Data Collection Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1254

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	0920-18ANU	Household Representative Questionnaire	4. Attachment 4_EN ES Paper Questionnaire - COPA Y1 COMBINED.pdf	NA	No		Fillable Fileable
Form and Instruction	0920-1254	Household Representative Questionnaire - Data Collection Instruments (combined English/Spanish)	Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	NA	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 2,700

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	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,700	-20	2,720
Annual IC Time Burden (Hours)	450	-4	454
Annual IC Cost Burden (Dollars)	3,825	533	3,292

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.