Information Collection

SHIELD Survey (English)

IC 257894 under ICR 202301-0920-007 · OMB 0920-1402.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1402 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- SHIELD Survey (English)	Form
0920- Survey (English) Att 6a_SHIELD Survey (English).docx	Form
0920- Survey (English) Att 6a_SHIELD Survey (English).docx	Form
Attachment 12_SHIELD Survey Screenshots.docx Survey Screenshots	IC Document
Attachment 12_SHIELD Survey Screenshots.docx Survey Screenshots	IC Document

IC Title:

SHIELD Survey (English)

Agency IC Tracking Number:

0920-23HK

Is this a Common Form? No

IC Status: New

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	0920-	Survey (English)	Att 6a_SHIELD Survey (English).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	1,667	1,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Screenshots	Attachment 12_SHIELD Survey Screenshots.docx	01/12/2023

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