Information Collection

Screener for Focus Groups

IC 194004 under ICR 201011-0920-007 · OMB 0920-0869.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3a Screener for Focus Groups	Form and Instruction
0920-09CJ_att3b_One-on-One Interview Guide OADS.06162010.docx	Other-Interview Guide
3a Screening Tool 0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx	Form and Instruction
3c Screener for One-on-One Surveys 0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.OADS.docx	Form and Instruction
3d Survey Instruments 0920-09CJ_att3d_Phase 2 One-on-One Surveys.OADS.docx	Form
3e Screener for Focus Groups 0920-09CJ_att3e_Phase 3 Screener for Focus Groups.OADS.docx	Form and Instruction

IC Title:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3a	Screening Tool	0920-09CJ_att3a_Screener for One-on-One Interviews.OADS.docx	Yes	Yes	Fillable Fileable
Other-Interview Guide			0920-09CJ_att3b_One-on-One Interview Guide OADS.06162010.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3c	Screener for One-on-One Surveys	0920-09CJ_att3c_Phase 2 Screener for One-on-One Surveys.OADS.docx	Yes	Yes	Fillable Fileable
Form	3d	Survey Instruments	0920-09CJ_att3d_Phase 2 One-on-One Surveys.OADS.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3e	Screener for Focus Groups	0920-09CJ_att3e_Phase 3 Screener for Focus Groups.OADS.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.