Information Collection

Non-temporary housing unit occupant - screening questionnaire

IC 191847 under ICR 201001-0923-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Non-temporary housing unit occupant - screening questionnaire	Form
Non-temporary housing unit occupant - screener Appendix I Screener (Displaced Person) 11 04 09.doc	Form

IC Title:

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	none	Non-temporary housing unit occupant - screener	Appendix I Screener (Displaced Person) 11 04 09.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 53 FR 30720

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	50	50
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.