Information Collection

Screening Form (NYBC)

IC 194328 under ICR 201008-0920-012 · OMB 0920-0873.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0920-10CM_Att3b_Screening Form (NYBC).docx	Other-WORD
0920-10CM_Att3b_Screening Form NYBC 11[1].15.2010-clean.docx	Other-Word
0920-10CM_Att4b_Consent Forms (NYBC).doc Consent Forms -- NYBC	IC Document
0920-10CM_Att5b2_Script for Recruitment (NYBC).doc Script for Recruitment	IC Document
0920-10CM_Att5b1_Recruitment Card Flyer (NYBC).doc Recruitment Card Flyer	IC Document
0920-10CM_Att5b3_Telephone Scripts (NYBC).doc Telephone Script	IC Document
0920-10CM_Att5b4_Reminder Letters (NYBC).doc Reminder Letters	IC Document
0920-10CM_Att4b_Consent Forms 8NYBC 11[1].15.2010-clean.docx 0920-10CM_Att4b_Consent Forms 8NYBC 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_Att3b_Screening Form (NYBC).docx		Yes	Yes	Fillable Printable
Other-Word			0920-10CM_Att3b_Screening Form NYBC 11[1].15.2010-clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 214

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	214	214
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Forms -- NYBC	0920-10CM_Att4b_Consent Forms (NYBC).doc	07/26/2010
Script for Recruitment	0920-10CM_Att5b2_Script for Recruitment (NYBC).doc	07/29/2010
Recruitment Card Flyer	0920-10CM_Att5b1_Recruitment Card Flyer (NYBC).doc	07/29/2010
Telephone Script	0920-10CM_Att5b3_Telephone Scripts (NYBC).doc	07/29/2010
Reminder Letters	0920-10CM_Att5b4_Reminder Letters (NYBC).doc	07/29/2010
0920-10CM_Att4b_Consent Forms 8NYBC 11[1].15.2010-clean	0920-10CM_Att4b_Consent Forms 8NYBC 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.