Information Collection

Screening Form

IC 198153 under ICR 201106-0920-012 · OMB 0920-0892.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0892 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form New form Screening Form	Form and Instruction
New form Attachment E Screening Questions for CDI Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc	Form and Instruction
Attachment D _ CDI ASSENT for 13-15 .doc Attachment D CDI Assent	IC Document
Attachment C _ADULT VERBAL CONSENTrevised.doc Attachment C Adult Verbal Consent	IC Document

IC Title:

Screening Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	New form	Attachment E Screening Questions for CDI	Attachment E - Screening Questions for Clostridium difficile Telephone Interview.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D CDI Assent	Attachment D _ CDI ASSENT for 13-15 .doc	06/16/2011
Attachment C Adult Verbal Consent	Attachment C _ADULT VERBAL CONSENTrevised.doc	06/16/2011

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