Information Collection

Number to Complete the Screener

IC 198468 under ICR 201107-0910-005 · OMB 0910-0703.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0703 can be found here:

Documents and Forms

Document Name Document Type
APPENDIX E - Screener.doc Other-Screener

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Number to Complete the 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
Other-Screener			APPENDIX E - Screener.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 69,118	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	69,118	69,118
Annual IC Time Burden (Hours)	2,304	2,304
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.