Individuals Screened/Coginitive testing

Facts for Consumers About Health

Documents and Forms

Document Name Document Type
Attachment B OMB 0955-0002.docx Other-telephone script
Attachment D OMB 0955-0002.docx Other-testing

Information Collection (IC) Details

IC Title:	Individuals Screened/Coginitive testing	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
Other-telephone script			Attachment B OMB 0955-0002.docx		No	No	Paper Only
Other-testing			Attachment D OMB 0955-0002.docx		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 %

	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

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.