Information Collection

Individual Questionnaire

IC 241479 under ICR 202004-0920-015 · OMB 0920-1293.

Documents and Forms

Document Name Document Type
Individual Questionnaire Form
Individual Questionnaire 24APR2020 Att3a_Individual Questionnaire.docx Form
Att4a_Field Team SOP.docx Field Team SOP IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual Questionnaire	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	Individual Questionnaire 24APR2020	Att3a_Individual Questionnaire.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,333	1,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Field Team SOP	Att4a_Field Team SOP.docx	04/22/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.