Information Collection

Individual Questionnaire

IC 234594 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 Individual Questionnaire	Form and Instruction
0920-18ANU Individual Questionnaire 5. EN Paper Questionnaire - Individual.docx	Form and Instruction
0920-18ANU Individual Questionnaire 5. EN Paper Questionnaire - Individual.docx	Form and Instruction
0920-18ANU Individual Questionnaire Spanish 5. ES Paper Questionnaire - Individual.docx	Form and Instruction
0920-18ANU Individual Questionnaire Spanish 5. ES Paper Questionnaire - Individual.docx	Form and Instruction
0920-1254 Individual Questionnaire - Data Collection Instruments ( Attachment 3_COPA Data Collection Instruments_combined 07APR2022.pdf	Form and Instruction
0920-1254 Individual Questionnaire - Data Collection Instruments ( 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?	Electronic Capability
Form and Instruction	0920-18ANU	Individual Questionnaire	5. EN Paper Questionnaire - Individual.docx	na	No	Fillable Fileable
Form and Instruction	0920-18ANU	Individual Questionnaire Spanish	5. ES Paper Questionnaire - Individual.docx	na	No	Fillable Fileable
Form and Instruction	0920-1254	Individual 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: 3,800

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	3,800	-200	4,000
Annual IC Time Burden (Hours)	1,267	267	1,000
Annual IC Cost Burden (Dollars)	10,770	3,520	7,250

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.