Information Collection

Telephone Screener

IC 194462 under ICR 201008-0925-005 · OMB 0925-0623.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0623 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Telephone Screener Form
1 Telephone Screener Attach 16 - Telephone Screener.doc Form
Attach 22 - Telephone Interview Script.doc Telephone Script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Telephone Screener	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	1	Telephone Screener	Attach 16 - Telephone Screener.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD	FR Citation: 67 FR 60776

Number of Respondents: 1,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,700	1,700
Annual IC Time Burden (Hours)	283	283
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Telephone Script	Attach 22 - Telephone Interview Script.doc	08/18/2010

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