Information Collection

Persons interviewed with short and Proxy interview

IC 178498 under ICR 200701-0920-006 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Document Name Document Type
Attachment 2c Proxy int.doc Instruction
MMP Attach 2B short questionnaire.doc Instruction
Attachment 2d MMP non response collection.doc Attachment 2d IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Persons interviewed with short and Proxy interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment 2c Proxy int.doc		Yes	No	Printable Only
Instruction			MMP Attach 2B short questionnaire.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 332	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	332	332
Annual IC Time Burden (Hours)	111	111
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 2d	Attachment 2d MMP non response collection.doc	06/07/2007

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