Information Collection

Aim 2.1 Web-based SCREENER and Questionnaire

IC 203730 under ICR 201208-0925-001 · OMB 0925-0669.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0669 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Aim 2.1 Web-based SCREENER and Questionnaire Form and Instruction
1 Web-based Screener MSM_OMB_Attach_2_A_Web-based_Screener_1_2013_V_1.0.pdf Form and Instruction
MSM_OMB_Attach_2_Web_based_Screener_Q_5_2102_V_3 0 pdf.pdf Web-based Screener and Questionnaire (Screenshots) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Aim 2.1 Web-based SCREENER and Questionnaire	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 and Instruction	1	Web-based Screener	MSM_OMB_Attach_2_A_Web-based_Screener_1_2013_V_1.0.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Web-based Screener and Questionnaire (Screenshots)	MSM_OMB_Attach_2_Web_based_Screener_Q_5_2102_V_3 0 pdf.pdf	08/15/2012

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