Information Collection

Screening Questionnaire

IC 198566 under ICR 201112-0920-013 · OMB 0920-0906.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0906 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening Questionnaire	Form
Screening Questionnaire Appendix D12 - Screening questionnaire 7-5-11.doc	Form
Appendix D12 - Screening questionnaire 5-11-11_CHN7.9.2011.doc Screener - Chinese	IC Document
Appendix D12 - Screening questionnaire 5-11-11 SPANISH.docx Screener - Spanish	IC Document

IC Title:

Screening Questionnaire

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	none	Screening Questionnaire	Appendix D12 - Screening questionnaire 7-5-11.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems 09-20-0136

FR Citation: 57 FR 62812

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screener - Chinese	Appendix D12 - Screening questionnaire 5-11-11_CHN7.9.2011.doc	12/14/2011
Screener - Spanish	Appendix D12 - Screening questionnaire 5-11-11 SPANISH.docx	12/14/2011

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