Information Collection

Baseline Questionnaire Part 2 - Home Characteristics

IC 198568 under ICR 201107-0920-004 · OMB 0920-0906.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0906 can be found here:

Documents and Forms

Document Name Document Type
Baseline Questionnaire Part 2 - Home Characteristics Form
Baseline Questionnaire (Home Characteristics) Part 2 REVISED_APPENDIX_D2_Baseline (Part 2 Home Characteristics)_October 20.11.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Questionnaire Part 2 - Home Characteristics	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
Form	N/A	Baseline Questionnaire (Home Characteristics) Part 2	REVISED_APPENDIX_D2_Baseline (Part 2 Home Characteristics)_October 20.11.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Epidemiological Studies and Surveillance of Disease Problems 0920-0136	FR Citation: 57 FR 62812

Number of Respondents: 832	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	832	832
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.