Information Collection

SHIELD Survey (Spanish)

IC 257895 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920- SHIELD Survey (Spanish) Form
0920- Survey (English) Att 6a_SHIELD Survey (English).docx Form
0920- Survey (English) Att 6a_SHIELD Survey (English).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SHIELD Survey (Spanish)	Agency IC Tracking Number:	0920-23HK

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	417	417
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.