Information Collection

YSI Program Users (Demographic Screener)

IC 204463 under ICR 201210-0920-004 · OMB 0920-0951.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
YSI Program Users (Demographic Screener)	Form
Demographic Screener Screenshots Att 4A_YSI Program Demographic Screener_10 05 2012.pdf	Form
Att 3A_YSI Announcement_ 9 17 2012.doc YSI Announcement	IC Document
Att 3B_YSI Landing Page_9 17 2012.pdf YSI Landing Page	IC Document
Att 3C_Follow Up Reminder_9 17 2012.doc Reminder Email	IC Document
Att 4B_Full Version YSI Program Demographic Screener_10 05 2012.doc Word Version Demographic Screener	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
Form	none	Demographic Screener Screenshots	Att 4A_YSI Program Demographic Screener_10 05 2012.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
YSI Announcement	Att 3A_YSI Announcement_ 9 17 2012.doc	09/27/2012
YSI Landing Page	Att 3B_YSI Landing Page_9 17 2012.pdf	09/27/2012
Reminder Email	Att 3C_Follow Up Reminder_9 17 2012.doc	09/27/2012
Word Version Demographic Screener	Att 4B_Full Version YSI Program Demographic Screener_10 05 2012.doc	10/05/2012

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