Information Collection

Household Screener

IC 188705 under ICR 200904-0920-005 · OMB 0920-0314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Household Screener	Form and Instruction
3 Household Screening Questionnaire NSFG 2009 ATTACH G4--Screener.doc	Form and Instruction
NSFG 2009 ATT G1-AdvanceLetters.doc NSFG 2009 ATT G1-AdvanceLetters	IC Document
NSFG 2009 ATT G3-ConsentForms.doc NSFG 2009 ATT G3-ConsentForms	IC Document
NSFG 2009 G2a -QA Brochure.pdf NSFG 2009 G2a -QA Brochure	IC Document
NSFG 2009 G2b-Confidentiality.pdf NSFG 2009 G2b-Confidentiality	IC Document

IC Title:

Household Screener

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	3	Household Screening Questionnaire	NSFG 2009 ATTACH G4--Screener.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 14,000

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	14,000	14,000
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NSFG 2009 ATT G1-AdvanceLetters	NSFG 2009 ATT G1-AdvanceLetters.doc	03/31/2009
NSFG 2009 ATT G3-ConsentForms	NSFG 2009 ATT G3-ConsentForms.doc	03/31/2009
NSFG 2009 G2a -QA Brochure	NSFG 2009 G2a -QA Brochure.pdf	03/31/2009
NSFG 2009 G2b-Confidentiality	NSFG 2009 G2b-Confidentiality.pdf	03/31/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.