Information Collection

Project One Screener

IC 198633 under ICR 201107-0920-007 · OMB 0920-0926.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0926 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment C1_Screener (English).docx	Other-Screener - English
Attachment C2_Screener (Spanish).docx Screener - Spanish	IC Document

IC Title:

Project One Screener

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
Other-Screener - English			Attachment C1_Screener (English).docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screener - Spanish	Attachment C2_Screener (Spanish).docx	07/20/2011

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