Information Collection

Number of Completes - Screener

IC 202839 under ICR 201211-0910-008 · OMB 0910-0724.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
APPENDIX 2_questionnaire_FINAL.doc	Other-Screener and Questionnaires
APPENDIX 4_consent.doc	Other-Appendix 4

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 21 CFR 202.1(e)(6)(i)

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
Other-Screener and Questionnaires			APPENDIX 2_questionnaire_FINAL.doc		Yes	Yes	Printable Only
Other-Appendix 4			APPENDIX 4_consent.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,688

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	9,688	9,688
Annual IC Time Burden (Hours)	323	323
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.