View Information Collection (IC)

View Information Collection (IC)

IC Title:	Pretesting Questionnaires and Definitions Used to Classify Health Care Group Quarters	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	1	Protocol	Enclosure 1 - Health Care GQs questionnaire and definitions protocol.docx		No		Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	20	0	20	0	0	0
Annual IC Time Burden (Hours)	35	0	35	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
OMB Letter	OMB letter - GQ health care cognitive testing_041223_clean.docx	04/14/2023
Consent Form	Enclosure 2 - Health Care GQs pretesting consent form_041223_clean.docx	04/14/2023

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