Web Survey Screener and Web Survey Screener Screenshots

Communications Research for the Development of Messages and Materials about Cytomegalovirus (CMV)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Web Survey Screener and Web Survey Screener Screenshots	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
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 %

	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

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.