Information Collection

Caregiver Survey Recruitment Screener

IC 203631 under ICR 201208-0920-003 · OMB 0920-0977.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0977 can be found here:

Documents and Forms

Document Name Document Type
Caregiver Survey Recruitment Screener Form
Caregiver Screener Att 11E_Caregiver Screener.docx Form
Spanish Caregiver Screener Att S11E_ Caregiver Screener Spanish.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Caregiver Survey Recruitment Screener	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	none	Caregiver Screener	Att 11E_Caregiver Screener.docx		Yes	Yes	Fillable Fileable
Form	none	Spanish Caregiver Screener	Att S11E_ Caregiver Screener Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.