Information Collection

Evaluation of Efficacy of Household Water Filtration/Treatment Devices in Households with Private Wells - Screening Questionnaire

IC 7138 under ICR 200612-0920-011 · OMB 0920-0670.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form None assigned Evaluation of Efficacy of Household Water Filtration/Treatment Devices in Households with Private Wells - Screening Questionnaire	Form and Instruction
None assigned Attach 4_Participant Screening Questionnaire 0920-0670 attachments (11-29-2006) final.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None assigned	Attach 4_Participant Screening Questionnaire	0920-0670 attachments (11-29-2006) final.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,200	-600	1,800
Annual IC Time Burden (Hours)	100	-200	300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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