NY Mail-in Screener

Biomonitoring of Great Lakes Populations Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0044 can be found here:

Documents and Forms

Document Name Document Type
NY Mail-in Screener Form
NY Mail-in Screener Att6b_NY_MailScreen_LA_20120619.docx Form
Att6a_NY_FctSht_LA_20120619.docx Screening cover letter and fact sheet IC Document

Information Collection (IC) Details

IC Title:	NY Mail-in Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	NY Mail-in Screener	Att6b_NY_MailScreen_LA_20120619.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 518	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	518	518
Annual IC Time Burden (Hours)	43	43
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Screening cover letter and fact sheet	Att6a_NY_FctSht_LA_20120619.docx	09/27/2012

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