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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.