Information Collection

Household Screening

IC 43643 under ICR 201207-0930-001 · OMB 0930-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Screening Question Household Screening	Form and Instruction
Screening Question Screening Questions PDF 3 - Attachment H.pdf	Form and Instruction
PDF 1 - Attachments A,C,D,E,L.pdf Attachments A,C,D,E,L	IC Document
PDF 4 - Attachments I,J.pdf Attachments I,J	IC Document
PDF 5 - Attachment K.pdf Attachment K	IC Document
PDF 6 - Attachments M,N,O.pdf Attachments M,N,O	IC Document
PDF 7 - Attachments P,Q.pdf Attachments P,Q	IC Document
PDF 8 - Attachments F,G,R.pdf Attachments F,G,R	IC Document
PDF 9 - Attachment S.pdf Attachment S	IC Document
Attachment T_1.pdf Comment	IC Document
Attachment T_2.pdf Response	IC Document

IC Title:

Household Screening

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Screening Questions	Screening Questions	PDF 3 - Attachment H.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 145,474

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	145,474	-45,626	191,100
Annual IC Time Burden (Hours)	12,074	-3,787	15,861
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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