Information Collection

Initial Telephone Screen

IC 46264 under ICR 201306-0990-003 · OMB 0990-0308.

Documents and Forms

Document Name Document Type
0990-0308 Appendix B.doc Other-screen

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Telephone Screen	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241.301

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-screen			0990-0308 Appendix B.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 835	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	835	595	240
Annual IC Time Burden (Hours)	278	198	80
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.