Information Collection

Screening Form (UNCG)

IC 194329 under ICR 201008-0920-012 · OMB 0920-0873.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0920-10CM_Att3c_Screening Form (UNCG).docx	Other-WORD
0920-10CM_Att4c_Consent Forms (UNCG).doc Consent Forms -- UNCG	IC Document
0920-10CM_Att5c1_Invitation to Intervention (UNCG).doc Invitation	IC Document
0920-10CM_Att5c2_Recruitment Flyer (UNCG).doc Recruitment Flyer	IC Document
0920-10CM_Att5c3_Recruitment Script (UNCG).doc Recruitment Script	IC Document
0920-10CM_Att5c4_Invitation to Email Screening (UNCG).doc Invitation to E-mail Screening	IC Document
0920-10CM_Att5c5_Reminder Scripts (UNCG).doc Reminder Script	IC Document
0920-10CM_Att5c6_Reminder Letter (UNCG).doc Reminder Letter	IC Document
0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean.docx 0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean	IC Document
0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean	IC Document
0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean	IC Document
0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean	IC Document
0920-10CM_Att5c6_Reminder Letter UNCG 11[1].15.2010-clean.docx 0920-10CM_Att5c6_Reminder Letter UNCG 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_Att3c_Screening Form (UNCG).docx		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)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Forms -- UNCG	0920-10CM_Att4c_Consent Forms (UNCG).doc	07/26/2010
Invitation	0920-10CM_Att5c1_Invitation to Intervention (UNCG).doc	07/29/2010
Recruitment Flyer	0920-10CM_Att5c2_Recruitment Flyer (UNCG).doc	07/29/2010
Recruitment Script	0920-10CM_Att5c3_Recruitment Script (UNCG).doc	07/29/2010
Invitation to E-mail Screening	0920-10CM_Att5c4_Invitation to Email Screening (UNCG).doc	07/29/2010
Reminder Script	0920-10CM_Att5c5_Reminder Scripts (UNCG).doc	07/29/2010
Reminder Letter	0920-10CM_Att5c6_Reminder Letter (UNCG).doc	07/29/2010
0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean	0920-10CM_Att4c_Consent Forms UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean	0920-10CM_Att5c1_Invitation Intervention UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean	0920-10CM_Att5c3_Recruitment Script UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean	0920-10CM_Att5c4_Invitation to Email Screening UNCG 11[1].15.2010-clean.docx	11/22/2010
0920-10CM_Att5c6_Reminder Letter UNCG 11[1].15.2010-clean	0920-10CM_Att5c6_Reminder Letter UNCG 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.