Information Collection

Participant Screener

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

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.