Information Collection

Intercept Interview Guide

IC 203849 under ICR 201303-0920-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 2t Intercept Guide.docx	Other-WORD
Att 3c Consent Form-Intercept.docx Att 3c Consent Form-Intercept	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

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-WORD			Att 2t Intercept Guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	233	233
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 3c Consent Form-Intercept	Att 3c Consent Form-Intercept.docx	03/06/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.