Information Collection

Telephone Screener

IC 194462 under ICR 201012-0925-005 · OMB 0925-0623.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Telephone Screener	Form
1 Telephone Screener Attach 16 - REVISED - Telephone Screener.doc	Form
Attach 22 - REVISED_Telephone Interview Script_11-10-2010.doc Telephone Script	IC Document

IC Title:

Telephone 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	1	Telephone Screener	Attach 16 - REVISED - Telephone Screener.doc		Yes	No	Printable Only

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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
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

table that charts IC Documents
Title	Document	Date Uploaded
Telephone Script	Attach 22 - REVISED_Telephone Interview Script_11-10-2010.doc	11/20/2010

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