Information Collection

Screeners and Survey Questionnaire

IC 191539 under ICR 200912-0925-002 · OMB 0925-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Screeners and Survey Questionnaire	Form and Instruction
Attachment D_Letter_Scripts_Emails_10_26_09.doc	Instruction
1 Survey Attachment C_HIP_Survey_11-18-09.doc	Form and Instruction

IC Title:

Screeners and Survey Questionnaire

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	Survey	Attachment C_HIP_Survey_11-18-09.doc		Yes	Yes	Paper Only
Instruction			Attachment D_Letter_Scripts_Emails_10_26_09.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 29 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,167	1,167
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.