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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Appendix A-Questionnaire .pdf	Other-Appendix A - Questionnaire
HPHC Survey Questions.pdf	Other-Survey Questions

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:

table that charts list of 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 %

table that charts list of burden
	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

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.