Information Collection

Global Appraisal of Individual Needs Modified Shore Screener

IC 199504 under ICR 201109-0930-005 · OMB 0930-0276.

Documents and Forms

Document Name Document Type
Form GAIN-MSS Global Appraisal of Individual Needs Modified Shore Screener Form and Instruction
GAIN-MSS GAIN-MSS Attachment C.11 GAIN-MSS.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Global Appraisal of Individual Needs Modified Shore 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
Form and Instruction	GAIN-MSS	GAIN-MSS	Attachment C.11 GAIN-MSS.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,330	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,320	5,320
Annual IC Time Burden (Hours)	426	426
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.