Information Collection

Caregiver Survey Recruitment Screener

IC 203631 under ICR 201305-0920-002 · OMB 0920-0977.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Caregiver Survey Recruitment Screener	Form
Caregiver Screener Att 11E_Caregiver Screener.docx	Form
Spanish Caregiver Screener Att S11E_ Caregiver Screener Spanish.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Form	none	Caregiver Screener	Att 11E_Caregiver Screener.docx		Yes	Yes	Fillable Fileable
Form	none	Spanish Caregiver Screener	Att S11E_ Caregiver Screener Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 800

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	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.