Information Collection

Intercept Interview Guide

IC 203849 under ICR 201208-0920-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 2d Intercept Guide.docx	Other-WORD
Att 3c Consent Form (Intercept Interview).docx Att 3c Consent Form (Intercept Interview)	IC Document
Att 6 Receipt Form.docx Att 6 Receipt Form	IC Document

IC Title:

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
Other-WORD			Att 2d Intercept Guide.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	233	233
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 3c Consent Form (Intercept Interview)	Att 3c Consent Form (Intercept Interview).docx	08/21/2012
Att 6 Receipt Form	Att 6 Receipt Form.docx	08/21/2012

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