Information Collection

Screening Questionnaire

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screening Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
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 %

	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

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.