Information Collection

Adult Questionnaire

IC 239057 under ICR 202305-0923-001 · OMB 0923-0063.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Questionnaire	Form and Instruction
Adult questionnaire M_Att16_AdltQstnnr_20200714_updt.docx	Form and Instruction
Adult questionnaire M_Att16_AdltQstnnr_20200714_updt.docx	Form and Instruction

IC Title:

Adult Questionnaire

Agency IC Tracking Number:

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	Adult questionnaire	M_Att16_AdltQstnnr_20200714_updt.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN 09â19â0001, ââRecords of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"

FR Citation: 76 FR 4432

Number of Respondents: 2,333

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	2,333	2,333
Annual IC Time Burden (Hours)	1,167	1,167
Annual IC Cost Burden (Dollars)	29,139	29,139

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.