View Information Collection (IC)

View Information Collection (IC)

IC Title:	NHIS 575 ACASI Field Interviews	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	575 ACASI Field Test	QDRL NHIS 575 Attach 1.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the US Population	FR Citation: 49 FR 37693

Number of Respondents: 575	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	575	0	0	0	0	0
Annual IC Time Burden (Hours)	575	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Letter to Dr. Schwab	QDRL NHIS A-CASI 500 letter-sexIDQ-final 0110 2012.docx	01/11/2012
Att 3 - NHIS Advance letter	QDRL NHIS 575 Attach 3.doc	01/11/2012
Att 2 - Manual for Field Reps	QDRL NHIS 575 Attach 2.docx	01/11/2012

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