Information Collection

Survey Participant Questionnaire

IC 245119 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⚠️ Notice: This information collection may be referencing outdated material.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 Survey Participant Questionnaire	Form and Instruction
Attachment_6d_Water Protocol_2024JULY16.docx	Instruction
0920-0950 Survey Participant Questionnaire Attachment_6b_Survey Participant Questionnaire_2024AUG29.docx	Form and Instruction
0920-0950 Survey Participant Questionnaire Attachment_6b_Survey Participant Questionnaire_2024AUG29.docx	Form and Instruction
0920-0950 Household Questionnaire Attachment_6c_Household Questionnaire_2024JULY16.docx	Form and Instruction
0920-0950 Household Questionnaire Attachment_6c_Household Questionnaire_2024JULY16.docx	Form and Instruction

IC Title:

Survey Participant Questionnaire

Agency IC Tracking Number:

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	Survey Participant Questionnaire	Attachment_6b_Survey Participant Questionnaire_2024AUG29.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0950	Household Questionnaire	Attachment_6c_Household Questionnaire_2024JULY16.docx		Yes	Yes	Fillable Fileable
Instruction			Attachment_6d_Water Protocol_2024JULY16.docx	N/A	No		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: 5,882

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	5,882	282	5,600
Annual IC Time Burden (Hours)	5,882	282	5,600
Annual IC Cost Burden (Dollars)	0	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.