Information Collection

Participant Screener

IC 198205 under ICR 201106-0920-014 · OMB 0920-0899.

Documents and Forms

Document Name Document Type
Participant Screener Form
Participant Screener - Seniors 65-80 Attachment 4 Senior Screener_R.doc Form
Participant Screener - Adults 25-64 Recently Hospitalize Attachment 3 HospitalizedScreener_R.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form	none	Participant Screener - Seniors 65-80	Attachment 4 Senior Screener_R.doc		No	No	Paper Only
Form	none	Participant Screener - Adults 25-64 Recently Hospitalized	Attachment 3 HospitalizedScreener_R.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 144	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	144	144
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.