Information Collection

12-Month Survey

IC 244220 under ICR 202310-0920-003 · OMB 0920-1333.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20FO 12-Month Survey	Form and Instruction
0920-20FO Att.4l-Month12 Survey-Revised Att.4l-Month12 Survey-Revised.docx	Form and Instruction
0920-20FO Att.4l-Month12 Survey-Revised Att.4l-Month12 Survey-Revised.docx	Form and Instruction

IC Title:

12-Month Survey

Agency IC Tracking Number:

092-1333

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	0920-20FO	Att.4l-Month12 Survey-Revised	Att.4l-Month12 Survey-Revised.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160, Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42434

Number of Respondents: 949

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	Previously Approved
Annual Number of Responses for this IC	949	0	949
Annual IC Time Burden (Hours)	237	0	237
Annual IC Cost Burden (Dollars)	0	-6,747	6,747

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.