Information Collection

Screening and Diagnosis Tool

IC 193175 under ICR 201006-0930-001 · OMB 0930-0312.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form A - DxInt. Sc Screening and Diagnosis Tool	Form and Instruction
Form A - DxInt. Sc Form A - DxInt. Screening A- DxInt. Screening.doc	Form and Instruction
Consent forms.pdf Consent Forms	IC Document

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form A - DxInt. Screening	Form A - DxInt. Screening	A- DxInt. Screening.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	255	255
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Forms	Consent forms.pdf	05/27/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.