Information Collection

Community Screener - Screened Injection Drug Users and High-risk heterosexual individuals

IC 200567 under ICR 201203-0920-006 · OMB 0920-0922.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Rev Attach 3a Eligibility Screener-Community Survey.docx	Instruction
Attach 7b _Venue Owner_Manager Script.doc Attach 7b _Venue Owner_Manager Script.	IC Document

IC Title:

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
Instruction			Rev Attach 3a Eligibility Screener-Community Survey.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 7b _Venue Owner_Manager Script.	Attach 7b _Venue Owner_Manager Script.doc	02/15/2012

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