Information Collection

Screening Questionnaire

IC 194314 under ICR 201008-0920-009 · OMB 0920-0872.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number Screening Questionnaire	Form
No number Screening Questionnaire Attachment 3a_Screening Questionnaires.07092010.docx	Form
3a Screening Questionaire 11_01-2010 Attachment 3a_Screening Questionnaires 11012010.docx	Form

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	No number	Screening Questionnaire	Attachment 3a_Screening Questionnaires.07092010.docx		Yes	No	Fillable Fileable
Form	3a	Screening Questionaire 11_01-2010	Attachment 3a_Screening Questionnaires 11012010.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 750

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	750	750
Annual IC Time Burden (Hours)	63	63
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.