Information Collection

ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)

IC 218545 under ICR 201509-0920-013 · OMB 0920-0856.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Document Name Document Type
ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset) Form and Instruction
ASQ Intake Questionnaire (Chinese - Subset) E-4 NQDW_ASQ_Intake Questionnaire_Subset_CHINESE.docx Form and Instruction
ASQ Intake Questionnaire (Korean - Subset) E-5 NQDW_ASQ_Intake Questionnaire_Subset_KOREAN.docx Form and Instruction
ASQ Intake Questionnaire (Vietnamese - Subset) E-6 NQDW_ASQ_Intake Questionnaire_Subset_VIETNAMESE.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ASQ Intake Questionnaire (Chinese, Korean, Vietnamese - Subset)	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 and Instruction	NA	ASQ Intake Questionnaire (Chinese - Subset)	E-4 NQDW_ASQ_Intake Questionnaire_Subset_CHINESE.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	ASQ Intake Questionnaire (Korean - Subset)	E-5 NQDW_ASQ_Intake Questionnaire_Subset_KOREAN.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	ASQ Intake Questionnaire (Vietnamese - Subset)	E-6 NQDW_ASQ_Intake Questionnaire_Subset_VIETNAMESE.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 116	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	116	116
Annual IC Time Burden (Hours)	2	2
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.