Information Collection

Screener for Follow-up Assessment of Matter of Balance Programs

IC 188657 under ICR 201003-0920-004 · OMB 0920-0818.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener for Follow-up Assessment of Matter of Balance Programs	Form
Follow-up Assessment for Matter of Balance Program - scr Attachment_2a_-_Screener_for_Matter_of_Balance_Evaluation.02-03-10.doc	Form

IC Title:

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	none	Follow-up Assessment for Matter of Balance Program - screener	Attachment_2a_-_Screener_for_Matter_of_Balance_Evaluation.02-03-10.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 167

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	167	-333	500
Annual IC Time Burden (Hours)	8	-17	25
Annual IC Cost Burden (Dollars)	0	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.