Information Collection

Respondent Screener

IC 192850 under ICR 201102-0920-004 · OMB 0920-0858.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Respondent Screener	Form
Respondent screener 16-17 year olds Attachment_3_Screener Young Adults 16-17 (2).doc	Form
Respondent screener 18-18 year olds Attachment_4_Screener Young Adults 18-19.doc	Form
Respondent screener parents of children 5-12 years old Attachment_5_Screener parents.doc	Form

IC Title:

Respondent 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	Available Electronically?	Electronic Capability
Form	none	Respondent screener 16-17 year olds	Attachment_3_Screener Young Adults 16-17 (2).doc	No	Paper Only
Form	none	Respondent screener parents of children 5-12 years old	Attachment_5_Screener parents.doc	No	Paper Only
Form	none	Respondent screener 18-18 year olds	Attachment_4_Screener Young Adults 18-19.doc	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 120

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	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	24	24
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.