Information Collection

SAMPLE VHF Symptom Monitoring Web Survey

IC 278400 under ICR 202512-0920-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25-0004 SAMPLE VHF Symptom Monitoring Web Survey	Form and Instruction
Form 0920-25-0004 Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey SAMPLE VHF Symptom Monitoring Web Survey	Form and Instruction
0920-25-0004 Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey.docx	Form and Instruction
0920-25-0004 Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-25-0004

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	0920-25-0004				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,298

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,894	12,894
Annual IC Time Burden (Hours)	1,232	1,232
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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