Information Collection

Online Survey Instrument

IC 192388 under ICR 202509-0920-001 · OMB 0920-0600.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0600 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Online Survey Instrument	Form and Instruction
Online Survey Instrument Webshots Online Survey Instrument	Form and Instruction
Online Survey Instrument Webshots Att. 4-Online Survey Instrument Webshots.docx	Form and Instruction
Online Survey Instrument Webshots Att. 4-Online Survey Instrument Webshots.docx	Form and Instruction
PDF of Online Survey Instrument.pdf PDF Online Survey Instrument	IC Document
PDF of Online Survey Instrument.pdf PDF Online Survey Instrument	IC Document

IC Title:

Online Survey Instrument

Agency IC Tracking Number:

0920-0600

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	140	-20	160
Annual IC Time Burden (Hours)	35	-5	40
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PDF Online Survey Instrument		09/04/2025

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

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