Information Collection

Field Feasibility Test Home Visit

IC 225819 under ICR 201702-0920-008 · OMB 0920-1176.

Documents and Forms

Document Name Document Type
Field Feasibility Test Home Visit Form and Instruction
Suggested Scripts and Data Collection Forms for Presumed Att 3b_Living SP Forms_Visit_170209.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Field Feasibility Test Home Visit	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	N/A	Suggested Scripts and Data Collection Forms for Presumed Living Participants	Att 3b_Living SP Forms_Visit_170209.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 356	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	356	356
Annual IC Time Burden (Hours)	356	356
Annual IC Cost Burden (Dollars)	8,270	8,270

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.