Information Collection

Adult Questionnaire

IC 229171 under ICR 202504-0920-017 · OMB 0920-0214.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0214 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Questionnaire	Form and Instruction
Sample Adult Questionnaire NHIS_2025 Adult Questionnaire	Form and Instruction
Sample Adult Questionnaire NHIS_2025 0920-0214 Sample Adult NHIS_2025_04_sponsor_report TEXT VERSION.docx	Form and Instruction
Sample Adult Questionnaire NHIS_2025 0920-0214 Sample Adult NHIS_2025_04_sponsor_report TEXT VERSION.docx	Form and Instruction
0920-0214 Sample Adult NHIS_2025_04_sponsor_report.pdf Sample Adult Questionnaire NHIS 2025 (pdf)	IC Document
0920-0214 Sample Adult NHIS_2025_04_sponsor_report.pdf Sample Adult Questionnaire NHIS 2025 (pdf)	IC Document

IC Title:

Adult Questionnaire

Agency IC Tracking Number:

0920-0214

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	n/a			N/A	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: 33,000

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	33,000	33,000
Annual IC Time Burden (Hours)	26,950	26,950
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample Adult Questionnaire NHIS 2025 (pdf)		05/22/2025

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

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