Information Collection

Screening Questionnaire

IC 201174 under ICR 201202-0923-001 · OMB 0923-0045.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0045 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening Questionnaire	Form
Katrina Registry Pilot Screener OMB Appendix E Screener January 2012.doc	Form

IC Title:

Screening Questionnaire

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	Katrina Registry Pilot Screener	OMB Appendix E Screener January 2012.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 53 FR 30720

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	133	133
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.