Information Collection

Screener for the Community Telephone Interview

IC 203870 under ICR 201208-0920-007 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener for the Community Telephone Interview	Form
Screener Att 4_CPPW Interview Screener_08 17 2012 V2.docx	Form

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
Form	none	Screener	Att 4_CPPW Interview Screener_08 17 2012 V2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22,400	22,400
Annual IC Time Burden (Hours)	373	373
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.