Information Collection

Family Online Survey

IC 267045 under ICR 202404-0906-005 · OMB 0906-0099.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Family Online Survey	Form and Instruction
3 Family Online Survey Appendix F_Disparities Instrument 3_ Family Online Survey.docx	Form and Instruction
3 Family Online Survey Appendix F_Disparities Instrument 3_ Family Online Survey 08012024.docx	Form and Instruction
Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL).docx Appendix F_Disparities Instrument 3_ Family Online Survey (RL)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	3	Family Online Survey	Appendix F_Disparities Instrument 3_ Family Online Survey 08012024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 210

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
Annual Number of Responses for this IC	210	210
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix F_Disparities Instrument 3_ Family Online Survey (RL)	Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL).docx	08/01/2024

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