Information Collection

Survey

IC 237213 under ICR 201907-0920-009 · OMB 0920-1277.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1277 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-19VJ Survey Form and Instruction
0920-19VJ CSAW Questionnaire Att 3 - CSAW Questionnaire.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey	Agency IC Tracking Number:	0920-19VJ

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	0920-19VJ	CSAW Questionnaire	Att 3 - CSAW Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 627	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	627	627
Annual IC Time Burden (Hours)	314	314
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.