Information Collection

Visit 1 screener

IC 46217 under ICR 201009-0920-006 · OMB 0920-0736.

Documents and Forms

Document Name Document Type
Form No number Visit 1 screener Form
No number Visit 1 screener Attachment E-1. V1 Screener Full Screen Shots.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Visit 1 screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	No number	Visit 1 screener	Attachment E-1. V1 Screener Full Screen Shots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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