Screener for the Community Telephone Interview

Evaluation of the Communities Putting Prevention to Work (CPPW) National Prevention Media Initiative

Documents and Forms

Document Name Document Type
Screener for the Community Telephone Interview Form
Screener Att 4_CPPW Interview Screener_08 17 2012 V2.docx Form

Information Collection (IC) Details

IC Title:	Screener for the Community Telephone Interview	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	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 %

	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

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.