Information Collection

Screening and Consent

IC 200737 under ICR 201201-0920-004 · OMB 0920-0923.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening and Consent	Form
Screen and Consent Att E-1 Screening and Consent Process_1-6-12 (REVISED 2-7-12).docx	Form
Att E-2 Email Notification and Reminders_1-6-12.doc Email Notification and Reminders	IC Document

IC Title:

Screening and Consent

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Screen and Consent	Att E-1 Screening and Consent Process_1-6-12 (REVISED 2-7-12).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34,660

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
Annual Number of Responses for this IC	34,660	34,660
Annual IC Time Burden (Hours)	1,155	1,155
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Email Notification and Reminders	Att E-2 Email Notification and Reminders_1-6-12.doc	01/06/2012

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