Information Collection

Adult Form

IC 275095 under ICR 202504-0920-027 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Form	Form and Instruction
Adult Form Adult Form	Form and Instruction
Adult Form Att 3_Adult forms_KJ.docx	Form and Instruction
Adult Form Att_3 Adult forms.pdf	Form and Instruction
Att 8_Adult Forms in REDCap.pdf Adult Redcap copy	IC Document
Att 8_Adult Forms in REDCap.pdf Adult Redcap copy	IC Document

IC Title:

Adult Form

Agency IC Tracking Number:

0920-24EG

Is this a Common Form? No

IC Status: New

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62811

Number of Respondents: 100

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
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Adult Redcap copy		09/22/2025

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

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