Information Collection

Screening Form (SUNY)

IC 194327 under ICR 201008-0920-012 · OMB 0920-0873.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0920-10CM_Att3a_Screening Form (SUNY).doc	Other-WORD
0920-10CM_Att4a_Consent Forms (SUNY).doc Consent Forms -- SUNY	IC Document
0920-10CM_Att5a1_Recruitment Script (SUNY).doc Recruitment Script	IC Document
0920-10CM_Att5a2_Contact and Appointment Card (SUNY).doc Contact and Appointment Card	IC Document
0920-10CM_Att5a3_Reminder Call Script (SUNY).doc Reminder Call Script	IC Document
0920-10CM_Att4a_Consent Forms SUNY 11[1].15.2010-clean.docx 0920-10CM_Att4a_Consent Forms SUNY 11[1].15.2010-clean	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
Other-WORD			0920-10CM_Att3a_Screening Form (SUNY).doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Forms -- SUNY	0920-10CM_Att4a_Consent Forms (SUNY).doc	07/26/2010
Recruitment Script	0920-10CM_Att5a1_Recruitment Script (SUNY).doc	07/26/2010
Contact and Appointment Card	0920-10CM_Att5a2_Contact and Appointment Card (SUNY).doc	07/29/2010
Reminder Call Script	0920-10CM_Att5a3_Reminder Call Script (SUNY).doc	07/26/2010
0920-10CM_Att4a_Consent Forms SUNY 11[1].15.2010-clean	0920-10CM_Att4a_Consent Forms SUNY 11[1].15.2010-clean.docx	11/22/2010

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