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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Attachment C1_Screener (English).docx Other-Screener - English
Attachment C2_Screener (Spanish).docx Screener - Spanish IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.