Information Collection

Household Screening

IC 43643 under ICR 201107-0930-002 · OMB 0930-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment H Household Screening	Form and Instruction
Attachment H Attachment H PDF 3 - Attachment H.pdf	Form and Instruction
PDF 1 - Attachments A,C,D,E,F,G.pdf Attachments A,C,D,E,F,G	IC Document
PDF 4 - Attachment I,J, K .pdf Attachment I,J, K	IC Document
PDF 7 - Attachment Q.pdf Attachment Q	IC Document
PDF 8 - Attachment R .pdf Attachment R	IC Document

IC Title:

Household Screening

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	Attachment H	Attachment H	PDF 3 - Attachment H.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 191,100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	191,100	-5,620	196,720
Annual IC Time Burden (Hours)	15,861	-467	16,328
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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