№ files_lp_4_process_3_101789
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Structured form collecting personal demographic and socioeconomic information from participants for statistical analysis in a public health study.
Year:
2021
Region / City:
United States
Topic:
Public health survey
Document Type:
Data collection form
Agency:
Centers for Disease Control and Prevention
Department:
National Center for Health Statistics
Approval Number:
OMB 0920-0222
Confidentiality:
Responses used only for statistical purposes
Target Population:
Study participants
Data Collected:
Demographics, education, employment, income
Expiration Date:
08/31/2021
Instructions Included:
Yes
Form Sections:
Source of awareness, Gender, Age, Marital status, Ethnicity, Race, Education, Employment, Household income
Statutory Basis:
Public Health Service Act, CIPSEA 2002
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The product description is provided for reference. Actual content and formatting may differ slightly.
Year:
2026
Country:
United States
Subject:
Public health survey and health status data collection
Document type:
Survey introduction and questionnaire excerpt
Organization:
National Center for Health Statistics
Parent organization:
Centers for Disease Control and Prevention
Regulatory reference:
Public Health Service Act Section 308(d); Confidential Information Protection and Statistical Efficiency Act
OMB Control Number:
0920-0222
Expiration date:
01/31/2026
Estimated response time:
15 minutes
Data protection:
Confidential statistical use of identifiable information
Participation conditions:
Voluntary participation with option to skip questions or withdraw
Contact for ethics questions:
NCHS Ethics Review Board
Contact phone:
1-800-223-8118
Survey mode:
Web questionnaire and phone interview
Main topics:
Language use, self-rated health status, chronic conditions, anxiety symptoms
Target population:
Members of the public participating in a health survey in the United States
Issuing body:
National Center for Chronic Disease Prevention & Health Promotion
Form type:
Data Management Plan (DMP)
OMB Control Number:
0920-1301
Expiration Date:
10/31/2026
Applicable to:
NOFO or Contract applications and awards
Project phases:
New Application; New Award; Evaluation Plan; Continuation; Final
Estimated Public Reporting Burden:
60 minutes per response
Subject:
Management, access, documentation, and preservation of public health data
Geographic reference:
Atlanta, GA
Responsible agency contact:
CDC Reports Clearance Officer
Year:
2025
Region / City:
Ahmedabad, Gujarat
Industry:
Product Management, Business Analysis, Agile
Document Type:
Resume
Organization:
Netskope Inc., De Soto Technologies, Cygnet Infotech Pvt. Ltd., Tech Ancubate Pvt. Ltd., Samyak Bazaar Pvt. Ltd.
Author:
Arpit Shah
Target Audience:
Employers, Recruiters, Industry Professionals
Period of Activity:
2015 - 2025
Date Approved:
2025
Date of Updates:
2025
Year:
2016
Issuing Organization:
Tennessee Valley Authority
Document Type:
Personnel Security Questionnaire (Short Form)
Form Number:
OMB No. 3316-0063
Expiration Date:
12/31/2016
Related Form:
Form TVA 1 – Application For Employment
Purpose:
Determination of eligibility for security clearance or access authorization
Legal Authority:
TVA Act (16 U.S.C. 831-831ee); Executive Order No. 10450; Atomic Energy Act of 1954, as amended; 5 U.S.C. 552a
Estimated Public Reporting Burden:
15 minutes per response
Location Referenced:
Chattanooga, TN; Washington, DC
Administering Office:
Agency Clearance Officer, Tennessee Valley Authority
Year:
2018
Country:
United States
Federal Agency:
U.S. Department of Housing and Urban Development
Office:
Office of Residential Care Facilities
Program:
National Housing Act Section 232 Healthcare Facility Insurance Program
OMB Control Number:
2502-0605
OMB Expiration Date:
03/31/2018
Legal Authority:
National Housing Act (12 USC 1701 et seq.); 24 CFR 5.212; 24 CFR 200.6; Housing and Community Development Act of 1987 (42 USC 3543(a))
Type of Document:
Personal financial disclosure form
Purpose:
Submission of financial information to obtain HUD mortgage insurance approval
Required Information:
Assets, liabilities, net worth, real property, stocks and bonds, insurance, legal proceedings, references
Confidentiality:
No confidentiality is assured
Certification Requirement:
Signature under penalty of criminal, civil, and administrative sanctions
Intended Applicants:
Individuals seeking HUD-insured mortgage financing under Section 232
Validity Condition:
Form valid only with currently valid OMB control number
Year:
2022
Country:
United States
Issuing agency:
U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support
OMB control number:
0584-0524
Expiration date:
12/31/2022
Legal framework:
Paperwork Reduction Act of 1995; Privacy Act of 1974
Document type:
Training evaluation survey form
Program:
Farm to School Producer Training
Subject:
Assessment of knowledge, perceptions, and intended implementation of farm to school sales strategies
Target audience:
Agricultural producers participating in farm to school training
Estimated completion time:
5 minutes per response
Data collection nature:
Voluntary information collection without personally identifiable information
Contact address:
1320 Braddock Place, Alexandria, VA 22306
Year:
2015
Region / City:
United States
Topic:
National Youth Tobacco Survey
Document Type:
Request for correction
Organization:
Centers for Disease Control and Prevention (CDC)
Author:
René A. Arrazola, MPH
Target Audience:
Public health officials, researchers, and policymakers
Effective Period:
2015
Approval Date:
January 16, 2015
Amendment Date:
N/A
Note:
This document is a request to update and correct a publicly posted version of the 2015 National Youth Tobacco Survey instrument on the www.Reginfo.gov
Organization:
RTI International
Headquarters:
Research Triangle Park, NC
Project Name:
Insiders Online Community
Related Campaign:
We Think Twice
Type of Document:
Youth Assent Form
Legal Framework:
Paperwork Reduction Act of 1995 (Pub. L. 104-13)
OMB Control Number:
0970-0401
OMB Expiration Date:
5/31/2027
Purpose:
Permission for youth participation in online marketing campaign activities
Target Audience:
Youth ages 13–21
Funding Source:
Public funds
Activities:
Online discussions, questionnaires, voting, content review, media feedback
Incentives:
Points redeemable for Amazon, Starbucks, or iTunes gift cards ($15 per 75 points)
Estimated Time per Activity:
15–20 minutes
Voluntary Participation:
Yes
Confidentiality:
Anonymous responses; username visible within platform
Contact Email:
[email protected]
Project Director:
Dr. Barri Burrus
Project Director Phone:
1-800-334-8571 ext. 25109
Office of Research Protection Phone:
1-866-214-2043
Year:
2026
Organization:
National Center for Health Statistics, Centers for Disease Control and Prevention
Document Type:
Questionnaire
Topic:
Public Health / Health Survey
Target Audience:
General U.S. population
Purpose:
Health research and statistical data collection
Estimated Completion Time:
20 minutes
Participation:
Voluntary
Confidentiality:
Responses kept confidential under CIPSEA and Public Health Service Act
OMB Control Number:
0920-0222
Expiration Date:
01/31/2026
Contact Information:
Ethics Review Board, NCHS, 1-800-223-8118
Survey Mode:
CAWI (web) and CATI (phone)
Year:
2023
Region / City:
United States
Topic:
Citizen Science, Crowdsourcing, Public Health Research
Document Type:
Official Agency Statement
Organization:
National Institutes of Health (NIH)
Author:
Mikia Currie, Chief, Project Clearance Branch
Target Audience:
Researchers, Program Staff, Federal Agencies, Public Participants
Effective Period:
July 26, 2023
Approval Date:
July 26, 2023
Amendment Date:
Not specified
Year:
2026
Country:
United States
Program:
National Flood Insurance Program (NFIP)
Subject:
Flood insurance claims process and customer experience
Document Type:
Survey questionnaire
Government Agency:
Federal Emergency Management Agency (FEMA)
Parent Department:
U.S. Department of Homeland Security
Regulatory Reference:
Paperwork Reduction Act information collection
OMB Control Number:
1601-0029
OMB Expiration Date:
December 30, 2026
Estimated Response Time:
5 minutes per response
Response Requirement:
Voluntary
Survey Sections:
Claim Start; Claim Adjustment
Contact Person:
Kelli Johnson
Contact Email:
[email protected]
Target Respondents:
NFIP flood insurance claimants
Data Collection Purpose:
Assessment of claimant satisfaction, expectations, communication channels, and claim adjustment experience
Year:
2026
Organization:
eXp South Africa
Document Type:
Consent Form
Subject:
Credit Rating Check and Personal Information Sharing
Required Documents:
Company registration documents, company resolution, proof of company address, ID documents, proof of address for all members
Signatory:
Authorized company representative
Target Audience:
Business owners and company representatives
Purpose:
To authorize credit rating checks and information sharing with service providers and regulatory bodies
Date of Signing:
_____/___________________-20
Country:
South Africa
Organization:
eXp South Africa
Company:
eXp Realty
Document Type:
Consent Form
Purpose:
Authorization to conduct a credit rating check and share personal information with relevant service providers
Related Procedure:
ITC Credit Check
Personal Information Collected:
Title, First Name, Surname, Address, Email, Gross Income, Nett Income, Monthly Rent
Required Attachments:
ID document, Payslip, Proof of residence not older than 3 months
Consent Requested:
Permission to share personal information and perform a credit rating check
Involved Entities:
Credit bureaus, Law enforcement, Fraud prevention bodies, Regulatory bodies
Signature Requirement:
Applicant signature and date
Applicable Context:
Credit assessment for an application process
Year:
2019
Country:
United States
Agency:
Transportation Security Administration
Department:
U.S. Department of Homeland Security
Subject:
Aviation security program amendments
Document Type:
Information collection notice
OMB Control Number:
1652-0003
Regulatory Reference:
49 CFR § 1544.105
Target Audience:
Aircraft Operators, Private Charter Operators, Twelve-Five Charter Operators
Submission Requirement:
Request for changes to an approved security program
Submission Deadline:
30–45 days before the intended effective date of an amendment
Compliance Oversight:
Routine onsite inspections, assessments, and tests by TSA
Contact Point:
Designated TSA official
Year:
2020
Country:
United States
Organization:
National Library of Medicine (NLM)
Program / System:
ClinicalTrials.gov Protocol Registration and Results System (PRS)
Type of Document:
Customer Satisfaction Survey Request for Approval
Information Collection Authority:
OMB Generic Clearance for the Collection of Routine Customer Feedback (OMB#: 0925-0648)
Expiration Date:
05/31/2021
Author / Responsible Official:
Anna Fine, PharmD
Respondent Category:
Individuals or Households
Target Respondents:
Users of the ClinicalTrials.gov PRS Guided Tutorials
Mode of Collection:
Web-based survey
Voluntary Participation:
Yes
Personally Identifiable Information Collected:
No
Incentives or Payments to Participants:
No
Estimated Number of Respondents:
3550
Estimated Time per Response:
4 minutes
Total Estimated Burden Hours:
237
Estimated Respondent Cost:
$6095.64
Estimated Federal Cost:
$1060.85
Federal Staff Role:
Customer Outreach Service Specialist (GS 13-2)
Data Dissemination:
Results not intended for public dissemination