Information Collection

ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)

IC 218545 under ICR 202207-0920-001 · OMB 0920-0856.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	Form and Instruction
ASQ Intake Questionnaire - subset (Chinese) 0856 NQDW Att D2_NQDW_ASQ_Intake Questionnaire_Subset_CHINESE.docx	Form and Instruction
ASQ Intake Questionnaire - subset (Chinese) 0856 NQDW Att D2_NQDW_ASQ_Intake Questionnaire_Subset_CHINESE.docx	Form and Instruction
ASQ Intake Questionnaire - subset (Korean) 0856 NQDW Att D3_NQDW_ASQ_Intake Questionnaire_Subset_KOREAN.docx	Form and Instruction
ASQ Intake Questionnaire - subset (Korean) 0856 NQDW Att D3_NQDW_ASQ_Intake Questionnaire_Subset_KOREAN.docx	Form and Instruction
ASQ Intake Questionnaire - subset (Vietnamese) 0856 NQDW Att D4_NQDW_ASQ_Intake Questionnaire_Subset_VIETNAMESE.docx	Form and Instruction
ASQ Intake Questionnaire - subset (Vietnamese) 0856 NQDW Att D4_NQDW_ASQ_Intake Questionnaire_Subset_VIETNAMESE.docx	Form and Instruction

IC Title:

ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	ASQ Intake Questionnaire - subset (Chinese)	0856 NQDW Att D2_NQDW_ASQ_Intake Questionnaire_Subset_CHINESE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ Intake Questionnaire - subset (Korean)	0856 NQDW Att D3_NQDW_ASQ_Intake Questionnaire_Subset_KOREAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	ASQ Intake Questionnaire - subset (Vietnamese)	0856 NQDW Att D4_NQDW_ASQ_Intake Questionnaire_Subset_VIETNAMESE.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 249

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	249	163	86
Annual IC Time Burden (Hours)	4	3	1
Annual IC Cost Burden (Dollars)	112	73	39

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.