Information Collection

Key Informats (screening)

IC 199549 under ICR 201307-0925-004 · OMB 0925-0649.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Key Informats (screening)	Form and Instruction
6 KI Screening Protocol Overview FINAL_HCS_SSA_ATTACH 12_KI SCREENING_Jan 2013.docx	Form and Instruction
FINAL_HCS_SSA_ATTACH 11_KI BROCHURE_Jan 2013.docx FINAL_HCS_SSA_ATTACH 11_KI BROCHURE_Jan 2013	IC Document
FINAL_HCS_SSA_ATTACH 10_KI LETTER_Jan 2013.docx FINAL_HCS_SSA_ATTACH 10_KI LETTER_Jan 2013	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 and Instruction	6	KI Screening Protocol Overview	FINAL_HCS_SSA_ATTACH 12_KI SCREENING_Jan 2013.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,520

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,520	1,913	1,607
Annual IC Time Burden (Hours)	293	164	129
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
FINAL_HCS_SSA_ATTACH 11_KI BROCHURE_Jan 2013	FINAL_HCS_SSA_ATTACH 11_KI BROCHURE_Jan 2013.docx	07/24/2013
FINAL_HCS_SSA_ATTACH 10_KI LETTER_Jan 2013	FINAL_HCS_SSA_ATTACH 10_KI LETTER_Jan 2013.docx	07/24/2013

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