Information Collection

Screening Questionnaire

IC 198566 under ICR 201107-0920-004 · OMB 0920-0906.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0906 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening Questionnaire	Form
Screening Questionnaire Appendix D12 - Screening questionnaire 7-5-11.doc	Form

IC Title:

Screening Questionnaire

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	Screening Questionnaire	Appendix D12 - Screening questionnaire 7-5-11.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems 09-20-0136

FR Citation: 57 FR 62812

Number of Respondents: 1,000

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	1,000	1,000
Annual IC Time Burden (Hours)	167	167
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.