Information Collection

Individuals Screened/Coginitive testing

IC 189373 under ICR 201211-0955-001 · OMB 0955-0002.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B OMB 0955-0002.docx	Other-telephone script
Attachment D OMB 0955-0002.docx	Other-testing

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-telephone script					No	No	Paper Only
Other-testing					No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 104

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	104	20	84
Annual IC Time Burden (Hours)	26	5	21
Annual IC Cost Burden (Dollars)	0	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.

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