Information Collection

SECOST Screening Instrument (Telephone)

IC 179148 under ICR 200703-0920-008 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SECOST Screening Instrument (Telephone)	Form
Telephone Screening Instrument Attachment 7 Telephone Screening Survey.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	None	Telephone Screening Instrument	Attachment 7 Telephone Screening Survey.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,160

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,160	4,160
Annual IC Time Burden (Hours)	347	347
Annual IC Cost Burden (Dollars)	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.