Information Collection

Provider-Based Sampling Eligibility Screener (PBS)

IC 202206 under ICR 201211-0925-001 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Document Name Document Type
Form 1.1 Provider-Based Sampling Eligibility Screener (PBS) Form and Instruction
1.1 Survey Provider Based Sampling Eligibility Screener 20120413.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider-Based Sampling Eligibility Screener (PBS)	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 and Instruction	1.1	Survey	Provider Based Sampling Eligibility Screener 20120413.docx		Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,125	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,125	3,125
Annual IC Time Burden (Hours)	1,042	1,042
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.