Information Collection

New York Mail-in Screener

IC 201466 under ICR 201203-0923-001 · OMB 0923-0044.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0044 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
New York Mail-in Screener	Form
New York Mail-in Screener Att6a_NY_MailScreen_LA.docx	Form
Att6_NY_ICFlow.docx New York Data Collection System	IC Document

IC Title:

New York Mail-in Screener

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	New York Mail-in Screener	Att6a_NY_MailScreen_LA.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
New York Data Collection System	Att6_NY_ICFlow.docx	02/27/2012

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