Information Collection

Adult Targeted Surveillance Survey Recruitment Screener

IC 203638 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Adult Targeted Surveillance Survey Recruitment Screener	Form
Adult Targeted Survey Screener Att 11G_ATSS Screener.docx	Form
Spanish Adult Targeted Survey Screener Att S11G_ATSS_Screener Spanish.docx	Form

IC Title:

Adult Targeted Surveillance 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Adult Targeted Survey Screener	Att 11G_ATSS Screener.docx		Yes	Yes	Fillable Fileable
Form	none	Spanish Adult Targeted Survey Screener	Att S11G_ATSS_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: 11,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 55 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,300	11,300
Annual IC Time Burden (Hours)	377	377
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.