Information Collection

Telephone Screening Interview for Hospitals

IC 179024 under ICR 201010-0920-001 · OMB 0920-0743.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0743 can be found here:

Documents and Forms

Document Name Document Type
Appx G-1_Telephone Screening Interview - Hospitals.doc Other-WORD
Appx I_Cover Letter.doc Appx I_Cover Letter IC Document
Appx J_Thank You Reminder Postcard.doc Appx J_Thank You Reminder Postcard IC Document
App K_Non-Responders Follow-Up Letter.doc App K_Non-Responders Follow-Up Letter IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Telephone Screening Interview for Hospitals	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
Other-WORD			Appx G-1_Telephone Screening Interview - Hospitals.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,897	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,897	3,897
Annual IC Time Burden (Hours)	325	325
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appx I_Cover Letter	Appx I_Cover Letter.doc	09/20/2010
Appx J_Thank You Reminder Postcard	Appx J_Thank You Reminder Postcard.doc	09/20/2010
App K_Non-Responders Follow-Up Letter	App K_Non-Responders Follow-Up Letter.doc	09/20/2010

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