Health Information National Trends Survey

Health Information National Trends Survey V (HINTS V) (NCI)

Documents and Forms

Document Name Document Type
Form 1 Health Information National Trends Survey Form and Instruction
1 B1- Instrument in English B1 - Instrument in English.docx Form and Instruction
B2 - Instrument in Spanish.docx B2 Instrument in Spanish IC Document

Information Collection (IC) Details

IC Title:	Health Information National Trends Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	B1- Instrument in English	B1 - Instrument in English.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,318	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-4,318	4,318
Annual IC Time Burden (Hours)	-2,159	2,159
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
B2 Instrument in Spanish	B2 - Instrument in Spanish.docx	02/18/2015

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