Information Collection

Telephone Screener (pages E1-E4 of the Baseline Questionnaire Form)

IC 179710 under ICR 200704-0920-001 · OMB 0920-0744.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Telephone Screener (pages E1-E4 of the Baseline Questionnaire Form)	Form and Instruction
Baseline Questionnaire ATTACHMENT E.data collection instrument.doc	Form and Instruction

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 and Instruction	None	Baseline Questionnaire	ATTACHMENT E.data collection instrument.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 52 FR 62812

Number of Respondents: 10,667

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,667	10,667
Annual IC Time Burden (Hours)	889	889
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.