Information Collection

Family/Caregiver Demographic Questionnaire

IC 267351 under ICR 202502-0906-001 · OMB 0906-0097.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3_Revised Family/Caregiver Demographic Questionnaire	Form and Instruction
Form 3_Revised Family Caregiver Demographic Questionaire Update 02.25.2025) Family/Caregiver Demographic Questionnaire	Form and Instruction
3_Revised Family Caregiver Demographic Questionaire Update 02.25.2 Attachment B3 - Family-Caregiver Demographic Questionnaire_Redline Update 02252025.docx	Form and Instruction
3_Revised Family Caregiver Demographic Questionaire Update 02.25.2 Attachment B3 - Family-Caregiver Demographic Questionnaire_Redline Update 02252025.docx	Form and Instruction

IC Title:

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	3_Revised				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 270

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	270	270
Annual IC Time Burden (Hours)	22	22
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.

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