Information Collection

Household Screener Questionnaire

IC 245118 under ICR 202409-0920-012 · OMB 0920-0950.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0950 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0950 Household Screener Questionnaire	Form and Instruction
0920-0950 Household Screener Questionnaire Attachment_6a_Household Screener Questionnaire_2024JULY16.docx	Form and Instruction
0920-0950 Household Screener Questionnaire Attachment_6a_Household Screener Questionnaire_2024JULY16.docx	Form and Instruction
Attachment_11a_Advance_Household_Letter_2024JULY16.pdf Advance Household Letter 11a-	IC Document
Attachment_11a_Advance_Household_Letter_2024JULY16.pdf Advance Household Letter 11a-	IC Document
Attachment_11c_Nonresponse_Letters_2024JULY16.pdf Nonresponse Letters	IC Document
Attachment_11c_Nonresponse_Letters_2024JULY16.pdf Nonresponse Letters	IC Document

IC Title:

Household Screener Questionnaire

Agency IC Tracking Number:

0920-0950

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	0920-0950	Household Screener Questionnaire	Attachment_6a_Household Screener Questionnaire_2024JULY16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 6,398

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	6,398	-1,902	8,300
Annual IC Time Burden (Hours)	747	-636	1,383
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advance Household Letter 11a-	Attachment_11a_Advance_Household_Letter_2024JULY16.pdf	09/23/2024
Nonresponse Letters	Attachment_11c_Nonresponse_Letters_2024JULY16.pdf	09/23/2024

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