Information Collection

Household Screener

IC 188705 under ICR 201009-0920-004 · OMB 0920-0314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Household Screener	Form and Instruction
3 Household Screening Questionnaire NSFG 2009 ATTACH G4--Screener.doc	Form and Instruction
NSFG 2009 ATT G1-AdvanceLetters.doc NSFG 2009 ATT G1-AdvanceLetters	IC Document
NSFG 2009 ATT G3-ConsentForms.doc NSFG 2009 ATT G3-ConsentForms	IC Document
NSFG 2009 G2a -QA Brochure.pdf NSFG 2009 G2a -QA Brochure	IC Document
NSFG 2009 G2b-Confidentiality.pdf NSFG 2009 G2b-Confidentiality	IC Document

IC Title:

Household Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	3	Household Screening Questionnaire	NSFG 2009 ATTACH G4--Screener.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 14,000

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	Previously Approved
Annual Number of Responses for this IC	14,000	14,000
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NSFG 2009 ATT G1-AdvanceLetters	NSFG 2009 ATT G1-AdvanceLetters.doc	03/31/2009
NSFG 2009 ATT G3-ConsentForms	NSFG 2009 ATT G3-ConsentForms.doc	03/31/2009
NSFG 2009 G2a -QA Brochure	NSFG 2009 G2a -QA Brochure.pdf	03/31/2009
NSFG 2009 G2b-Confidentiality	NSFG 2009 G2b-Confidentiality.pdf	03/31/2009

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