Information Collection

Web Survey Screener and Web Survey Screener Screenshots

IC 202907 under ICR 201206-0920-007 · OMB 0920-0947.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Web Survey Screener and Web Survey Screener Screenshots	Form and Instruction
Web Survey Attachment 3E Web Survey Screener Screenshots Rev 9 5.docx	Form and Instruction
Attachment 3D Web Survey Screener (rev08282012).docx Attachment 3D Web Survey Screener (rev08282012)	IC Document

IC Title:

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 and Instruction	none	Web Survey	Attachment 3E Web Survey Screener Screenshots Rev 9 5.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,800	4,800
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 3D Web Survey Screener (rev08282012)	Attachment 3D Web Survey Screener (rev08282012).docx	09/07/2012

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