Information Collection

Screening Data

IC 204570 under ICR 201210-0930-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Screening Form Screening Data	Form and Instruction
Screening Form Screening Form B1. Screening Form.pdf	Form and Instruction

IC Title:

Screening Data

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 and Instruction	Screening Form	Screening Form	B1. Screening Form.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	5,382	5,382
Annual IC Time Burden (Hours)	1,346	1,346
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.