Information Collection

Online Screener and Survey

IC 190374 under ICR 201006-0920-005 · OMB 0920-0825.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Revised 0920-08AA_Attachment 3F_Online Screener & Survey[15-25].doc	Other-online survey

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
Other-online survey			Revised 0920-08AA_Attachment 3F_Online Screener & Survey[15-25].doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	117	50	67
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.