Information Collection

Screener

IC 202181 under ICR 201205-0910-004 · OMB 0910-0736.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0736 can be found here:

Documents and Forms

Document Name Document Type
Appendix A-Questionnaire .pdf Other-Appendix A - Questionnaire
HPHC Survey Questions.pdf Other-Survey Questions

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey Questions			HPHC Survey Questions.pdf		Yes	Yes	Printable Only
Other-Appendix A - Questionnaire			Appendix A-Questionnaire .pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.