Information Collection

Household Screener Questionnaire

IC 245118 under ICR 202603-0920-003 · OMB 0920-0950.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0950 Household Screener Questionnaire 17APR2025 Household Screener Questionnaire	Form and Instruction
0920-0950 Household Screener Questionnaire 17APR2025 0920-0950 Attachment_6a_Household Screener Questionnaire_2025APR16.docx	Form and Instruction
Attachment_11a_Advance_Household_Letter_2024JULY16.pdf Advance Household Letter 11a-	IC Document
Attachment_11c_Nonresponse_Letters_2024JULY16.pdf Nonresponse Letters	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	0920-0950			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: 6,398

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	6,398	6,398
Annual IC Time Burden (Hours)	747	747
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advance Household Letter 11a-		09/23/2024
Nonresponse Letters		09/23/2024

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

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