Information Collection

Participant Screener and Recruitment Form

IC 200324 under ICR 201112-0920-001 · OMB 0920-0915.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0915 can be found here:

Documents and Forms

Document Name Document Type
Participant Screener and Recruitment Form Form
Screener Attachment 5_Participant Screener and Recruitment Script (100511) (3).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Screener and Recruitment Form	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	none	Screener	Attachment 5_Participant Screener and Recruitment Script (100511) (3).docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	24	24
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.