Information Collection

Questionnaire, web (Att. K-L)

IC 239169 under ICR 202311-0920-009 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0822 Questionnaire, web (Att. K-L)	Form and Instruction
Form 0920-0822 Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean Questionnaire, web (Att. K-L)	Form and Instruction
Form 0920-0822 Att L_Web_Phone Screeners and Survey Instrument_Spanish Questionnaire, web (Att. K-L)	Form and Instruction
0920-0822 Att K_Web_Phone Screeners and Survey Instrument_English_ Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean.docx	Form and Instruction
0920-0822 Att K_Web_Phone Screeners and Survey Instrument_English_ Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean.docx	Form and Instruction
0920-0822 Att L_Web_Phone Screeners and Survey Instrument_Spanish Att L_Web_Phone Screeners and Survey Instrument_Spanish.docx	Form and Instruction
0920-0822 Att L_Web_Phone Screeners and Survey Instrument_Spanish Att L_Web_Phone Screeners and Survey Instrument_Spanish.docx	Form and Instruction

IC Title:

Questionnaire, web (Att. K-L)

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

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	0920-0822	Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean	Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0822	Att L_Web_Phone Screeners and Survey Instrument_Spanish	Att L_Web_Phone Screeners and Survey Instrument_Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 26,667

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	26,667	26,667
Annual IC Time Burden (Hours)	11,111	11,111
Annual IC Cost Burden (Dollars)	0	0

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.