Information Collection

Screener Document

IC 188039 under ICR 200902-0920-007 · OMB 0920-0811.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0811 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Screener Document	Form and Instruction
1 In-Depth Interview Screener Attachment 2- Screener Instrument for Nurses_Counselors_Psychologists_A.doc	Form and Instruction

IC Title:

Screener Document

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	1	In-Depth Interview Screener	Attachment 2- Screener Instrument for Nurses_Counselors_Psychologists_A.doc		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 96

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	96	96
Annual IC Time Burden (Hours)	16	16
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.