Information Collection

Adult Targeted Surveillance Survey - screener

IC 203638 under ICR 201305-0920-002 · OMB 0920-0977.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Targeted Surveillance Survey - screener	Form
Adult Targeted Surveillance Survey - telephone screener Att 7C_ATSS_PhoneInterview.docx	Form
Adult Targeted Surveillance Survey telephone screener- S Att 7C-S_ATSS_PhoneInterview_SP.docx	Form
Att 7D_ATSS_ItemSources_2013_0718.pdf Att 7D_ATSS_ItemSources_2013_0718	IC Document

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
Form	none	Adult Targeted Surveillance Survey - telephone screener	Att 7C_ATSS_PhoneInterview.docx		Yes	Yes	Fillable Fileable
Form	none	Adult Targeted Surveillance Survey telephone screener- Spanish	Att 7C-S_ATSS_PhoneInterview_SP.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: 13,749

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13,749	13,749
Annual IC Time Burden (Hours)	458	458
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 7D_ATSS_ItemSources_2013_0718	Att 7D_ATSS_ItemSources_2013_0718.pdf	08/06/2013

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