Information Collection

Line 1 Pretest Facility Screener

IC 183888 under ICR 200802-0920-012 · OMB 0920-0780.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0780 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Line 1 Pretest Facility Screener	Form
1 Pretest Facility Screener OMB Attachment F-Pretest Facility Screener_061108.doc	Form

IC Title:

Line 1 Pretest Facility Screener

Agency IC Tracking Number:

Is this a Common Form? Yes

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	1	Pretest Facility Screener	OMB Attachment F-Pretest Facility Screener_061108.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 25

Number of Respondents for Small Entity: 10

Affected Public: Private Sector

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

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	25	25
Annual IC Time Burden (Hours)	4	4
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.