Quantitative Household Survey

Central America Water and Sanitation Program Sustainability Evaluation and Qualitative Interview

Documents and Forms

Document Name Document Type
REVISED_Attachment 4_4HouseholdSurvey_Nov 10 2011.doc Instruction
Attch8ConsentScriptHousehold.docx Household Consent Script IC Document

Information Collection (IC) Details

IC Title:	Quantitative Household Survey	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
Instruction			REVISED_Attachment 4_4HouseholdSurvey_Nov 10 2011.doc		No		Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 256	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	256	256
Annual IC Time Burden (Hours)	192	192
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Household Consent Script	Attch8ConsentScriptHousehold.docx	10/06/2011

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