Information Collection

Screening and Contact with Women

IC 181261 under ICR 200707-0920-004 · OMB 0920-0756.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening and Contact with Women	Form and Instruction
Screening Form (NC) Appendix Q - Screening form_NC.doc	Form and Instruction
Participant Contact Form Appendix M-Participant contact form.doc	Form and Instruction
Screening Form for Women (FL) Appendix L- Screening form_Florida.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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Screening Form (NC)	Appendix Q - Screening form_NC.doc	No	No	Paper Only
Form and Instruction	None	Participant Contact Form	Appendix M-Participant contact form.doc	No	No	Paper Only
Form and Instruction	None	Screening Form for Women (FL)	Appendix L- Screening form_Florida.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 55

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
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	10	10
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.