Information Collection

Adult Proxy Survey - Adults 18 or older

IC 232647 under ICR 201808-0920-003 · OMB 0920-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1240 can be found here:

Documents and Forms

Document Name Document Type
Adult Proxy Survey - Adults 18 or older Form and Instruction
Adult Proxy Survey - English E-3 Adult-Proxy Survey -- English.docx Form and Instruction
Adult Proxy Survey - Spanish E-9 Adult-Proxy Survey -- Spanish.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Adult Proxy Survey - Adults 18 or older	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	Adult Proxy Survey - English	E-3 Adult-Proxy Survey -- English.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Adult Proxy Survey - Spanish	E-9 Adult-Proxy Survey -- Spanish.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750	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	750	750
Annual IC Time Burden (Hours)	288	288
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.