Information Collection

Interview Questionnaire

IC 180565 under ICR 202503-0920-027 · OMB 0920-0740.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interview Questionnaire	Form and Instruction
2024 Programming Questionnaire - English Interview Questionnaire	Form and Instruction
Form 0920-25-0058 MMP Questionnaire Interview Questionnaire	Form
Form 0920-25-0058 MMP Questionnaire _SPANISH Interview Questionnaire	Form
2024 Programming Questionnaire - English Att 5a MMP 2024-2026 Questionnaire English.pdf	Form and Instruction
2024 Programming Questionnaire - English Att 5a MMP 2024-2026 Questionnaire English.pdf	Form and Instruction
0920-25-0058 MMP Questionnaire Att 1b_2024 EN MMP Paper Questionnaire v24.2_Clean.pdf	Form
0920-25-0058 MMP Questionnaire Att 1b_2024 EN MMP Paper Questionnaire v24.2_Clean.pdf	Form
0920-25-0058 MMP Questionnaire _SPANISH Att 1d_2024 SP MMP Paper Questionnaire v24.2_Clean.pdf	Form
0920-25-0058 MMP Questionnaire _SPANISH Att 1d_2024 SP MMP Paper Questionnaire v24.2_Clean.pdf	Form
Att 5b MMP 2024-2026 Questionnaire Spanish.pdf 2024 Programming Questionnaire - Spanish	IC Document
Att 5b MMP 2024-2026 Questionnaire Spanish.pdf 2024 Programming Questionnaire - Spanish	IC Document

IC Title:

Agency IC Tracking Number:

0920-0740-25-0058

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Yes	Yes	Fillable Fileable
Form	0920-25-0058	Yes	Yes	Fillable Fileable
Form	0920-25-0058	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,760

Number of Respondents for Small Entity: 7,520

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	7,760	7,760
Annual IC Time Burden (Hours)	5,173	5,173
Annual IC Cost Burden (Dollars)	134,015	134,015

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
2024 Programming Questionnaire - Spanish		04/10/2024

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

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