Information Collection

Adult Questionnaire

IC 229171 under ICR 202303-0920-002 · OMB 0920-0214.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Questionnaire	Form and Instruction
Adult Questionnaire	Form and Instruction
Attachment 9b 2023 Q2 Additions to Sample Adult Questionnaire 02-13-2023.docx	Other-WORD
Attachment 9b 2023 Q2 Additions to Sample Adult Questionnaire 02-13-2023.docx	Other-WORD
2023 NHIS Sample Adult Questionnaire Att 9b - 2023 NHIS Sample Adult Questionnaire.101322.pdf	Form and Instruction
2023 NHIS Sample Adult Questionnaire Att 9b - 2023 NHIS Sample Adult Questionnaire.101322.pdf	Form and Instruction
Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf Additional COVID Questions	IC Document
Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf Additional COVID Questions	IC Document

IC Title:

Adult Questionnaire

Agency IC Tracking Number:

0920-22IA

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	None	2023 NHIS Sample Adult Questionnaire	Att 9b - 2023 NHIS Sample Adult Questionnaire.101322.pdf		Yes	Yes	Fillable Fileable
Other-WORD			Attachment 9b 2023 Q2 Additions to Sample Adult Questionnaire 02-13-2023.docx		No		Paper Only

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: 30,000

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	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	22,500	22,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Additional COVID Questions	Att 1 - 2021 Sample Adult Covid-19 Vaccination Questions.pdf	02/05/2021

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