Information Collection

Screener

IC 198633 under ICR 201201-0920-010 · OMB 0920-0926.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener	Form
Project One Screener Attachment C1_Screener (English)PROJ1Dec9REVISEDFINALcleancopy.doc	Form
Spanish Project One Screener Attachment C2_Screener (SPANISH)PROJ1Dec9REVISEDFINALcleancopy.doc	Form

IC Title:

Screener

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	Project One Screener	Attachment C1_Screener (English)PROJ1Dec9REVISEDFINALcleancopy.doc		Yes	No	Printable Only
Form	none	Spanish Project One Screener	Attachment C2_Screener (SPANISH)PROJ1Dec9REVISEDFINALcleancopy.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 320

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.