Information Collection

Head of Household (Pre-test 2, rural feasibility pilot in Garrett County, full implementation pilot in Baltimore City) Screener Questionnaire

IC 250648 under ICR 202208-0920-008 · OMB 0920-1356.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-22HW Head of Household (Pre-test 2, rural feasibility pilot in Garrett County, full implementation pilot in Baltimore City) Screener Questionnaire	Form and Instruction
0920-22HW Screening Questionnaire Attachment I_Screener Questionnaire.docx	Form and Instruction
0920-22HW Screening Questionnaire Attachment I_Screener Questionnaire.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-22HW

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	0920-22HW	Screening Questionnaire	Attachment I_Screener Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,808

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	2,808	2,808
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

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.