Focus Group Screener for Adult Women

Evaluation of Health Communication Messages for Infertility Prevention Campaign

Documents and Forms

Document Name Document Type
VS_0920-08AA_Attachment 3E_FG Screener[Adult Women].doc Other-Screener

Information Collection (IC) Details

IC Title:	Focus Group Screener for Adult Women	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener			VS_0920-08AA_Attachment 3E_FG Screener[Adult Women].doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 114	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	Previously Approved
Annual Number of Responses for this IC	114	-12	126
Annual IC Time Burden (Hours)	10	-1	11
Annual IC Cost Burden (Dollars)	0	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.