Information Collection

Respondent Screener

IC 192850 under ICR 201005-0920-001 · OMB 0920-0858.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0858 can be found here:

Documents and Forms

Document Name Document Type
Respondent Screener Form
Respondent screener 16-17 year olds Attachment_3_REV_Screener Young Adultsage16-17_REV.doc Form
Respondent screener 18-18 year olds Attachment_4__REV_4_23_ScreenerYoun Adults age18-19.doc Form
Respondent screener parents of children 5-12 years old Attachment_5__4_23_REVScreener_parents (2).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Respondent Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Respondent screener 16-17 year olds	Attachment_3_REV_Screener Young Adultsage16-17_REV.doc	No	No	Paper Only
Form	none	Respondent screener 18-18 year olds	Attachment_4__REV_4_23_ScreenerYoun Adults age18-19.doc	No	No	Paper Only
Form	none	Respondent screener parents of children 5-12 years old	Attachment_5__4_23_REVScreener_parents (2).doc	No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.