View Information Collection (IC)

View Information Collection (IC)

IC Title:	ACASI field interviews for NHIS	Agency IC Tracking Number:

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	none	ACASI field interviews	Attach 1 ACASI Qs-final.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	50	0	0	0	0	0
Annual IC Time Burden (Hours)	55	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Field test observation form	Attach 2- CAPI & ACASI Observation Form-final.doc	10/12/2011
Advance letter	Attach 3 Advance Letter-final.pdf	10/12/2011
Letter to Dr. Schwab	QDRL NHIS A-CASI 50 letter-final.doc	10/12/2011

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