View Information Collection (IC)

View Information Collection (IC)

IC Title:	PATH/Baseline- Adults Household Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Household Screener	3a - English. PATH Wave 1 Household Screener 7.5 2013-06-10.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: NIH Privacy Act System of Records 09-25-0200 Clinical, Basic Population-based research studies of NIH, HHS/NIH/OD	FR Citation: 67 FR 60741

Number of Respondents: 104,725	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	104,725	0	0	3,742	0	100,983
Annual IC Time Burden (Hours)	24,436	0	0	-4,176	0	28,612
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
3a	3a. Spanish. PATH Wave 1 Household Screener 7.5 2013-06-10.pdf	06/28/2013

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