Information Collection

Screening Interview

IC 184629 under ICR 201202-0920-001 · OMB 0920-0805.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Screening Interview	Form
1 Household Screening Interview for Telephone Interviewing Attachment 2a. Household Screening Interview.doc	Form

IC Title:

Screening Interview

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	1	Household Screening Interview for Telephone Interviewing	Attachment 2a. Household Screening Interview.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,700

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	Previously Approved
Annual Number of Responses for this IC	14,700	-85,800	100,500
Annual IC Time Burden (Hours)	735	-2,615	3,350
Annual IC Cost Burden (Dollars)	0	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.