Household Roster

[NCHS] National Health Interview Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0214 can be found here:

Documents and Forms

Document Name Document Type
Household Roster Form and Instruction
Household Roster Form and Instruction
2023 NHIS Roster Questionnaire Att 9a - 2023 NHIS Roster Questionnaire.pdf Form and Instruction
2023 NHIS Roster Questionnaire Att 9a - 2023 NHIS Roster Questionnaire.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Household Roster	Agency IC Tracking Number:	0920-0214

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	None	2023 NHIS Roster Questionnaire	Att 9a - 2023 NHIS Roster Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 36,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	36,000	36,000
Annual IC Time Burden (Hours)	2,400	2,400
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.