Information Collection

Household Members - Household Study Form

IC 228818 under ICR 201710-0920-016 · OMB 0920-1039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1039 can be found here:

Documents and Forms

Document Name Document Type
Household Members - Household Study Form Form
ORCHARDS - Household Study Form Att. C4a - Household study form.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Household Members - Household Study Form	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	NA	ORCHARDS - Household Study Form	Att. C4a - Household study form.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42484

Number of Respondents: 720	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	1,440	1,440
Annual IC Time Burden (Hours)	240	240
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.