Information Collection

Screener Document

IC 188039 under ICR 200908-0920-004 · OMB 0920-0811.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 In-Depth Interview Screener Screener Document	Form and Instruction
1 In-Depth Interview Screener Attachment 2- Screener Instrument for Nurses_Counselors_Psychologists_Administrators.09-0121.doc	Form and Instruction
Attachment 2- Screener Instrument for Nurses_Counselors_Teachers_Administrators 09-0811.final.doc Revised Screener Instrument	IC Document

IC Title:

Screener Document

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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				No	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	Previously Approved
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
Revised Screener Instrument		08/20/2009

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

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