Information Collection

SHIELD Survey (English)

IC 257894 under ICR 202403-0920-003 · OMB 0920-1402.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1402 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1402 SHIELD Survey (English)	Form and Instruction
0920-1402 Attachment 6A SHIELD Survey (English) Attachment 6A SHIELD Survey (English).docx	Form and Instruction
0920-1402 Attachment 6A SHIELD Survey (English) Attachment 6A SHIELD Survey (English).docx	Form and Instruction
Attachment 12_SHIELD Survey Screenshots.docx Survey Screenshots	IC Document
Attachment 12_SHIELD Survey Screenshots.docx Survey Screenshots	IC Document

IC Title:

SHIELD Survey (English)

Agency IC Tracking Number:

0920-1402

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	0920-1402	Attachment 6A SHIELD Survey (English)	Attachment 6A SHIELD Survey (English).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,000	0	2,000
Annual IC Time Burden (Hours)	1,666	-1	1,667
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Screenshots	Attachment 12_SHIELD Survey Screenshots.docx	01/12/2023

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