Information Collection

Web Survey Screener and Web Survey Screener Screenshots

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

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

View Information Collection (IC)

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.