Information Collection

Demographic Survey

IC 247304 under ICR 202205-0920-011 · OMB 0920-1351.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1351 Demographic Survey	Form and Instruction
0920-1351 Demographic Survey BIRCH Revised Attachment I Demographic Survey 5-12-2022.docx	Form and Instruction
0920-1351 Demographic Survey BIRCH Revised Attachment I Demographic Survey 5-12-2022.docx	Form and Instruction
BIRCH Changes to Attachment I Demographic Survey 5-12-2022.docx Changes to Att I. Demographic Survey (track changes)	IC Document
BIRCH Changes to Attachment I Demographic Survey 5-12-2022.docx Changes to Att I. Demographic Survey (track changes)	IC Document

IC Title:

Demographic Survey

Agency IC Tracking Number:

0920-1351-22FR

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	0920-1351	Demographic Survey	BIRCH Revised Attachment I Demographic Survey 5-12-2022.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

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	120	120
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Changes to Att I. Demographic Survey (track changes)	BIRCH Changes to Attachment I Demographic Survey 5-12-2022.docx	05/25/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.