Information Collection

Background and Demographic Information Form

IC 195559 under ICR 202503-0915-001 · OMB 0915-0338.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Background and Demographic Information Form	Form and Instruction
Form 2 Background Form Background and Demographic Information Form	Form and Instruction
Form 1 Demographic Form Background and Demographic Information Form	Form and Instruction
2 Background Form B1 - Background Form.docx	Form and Instruction
2 Background Form B1 - Background Form.docx	Form and Instruction
1 Demographic Form 0915-0338_MCHB_HSMED_Demographic_Form_Redline_03052025.docx	Form and Instruction
1 Demographic Form 0915-0338_MCHB_HSMED_Demographic_Form_Redline_03052025.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	2				Yes	Yes	Fillable Fileable
Form and Instruction	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45,450

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	45,450	45,450
Annual IC Time Burden (Hours)	27,270	27,270
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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