Group Intervention Sereening Questionnaire

WHAM: Women Health and Mindfulness Program

Documents and Forms

Document Name Document Type
19144_ID (WHAM) Women's Health and Mindfulness Program- Group Intervention Screening Questionnaire.docx Other-survey
4B_Group Intervention consent form_13243_28june2013.doc Other-Consent
WHAM Screening Instrument Screen Shots.docx Other-ScreenShot

Information Collection (IC) Details

IC Title:	Group Intervention Sereening Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Consent	4B_Group Intervention consent form_13243_28june2013.doc	No		Printable Only
Other-ScreenShot	WHAM Screening Instrument Screen Shots.docx	No		Printable Only
Other-survey	19144_ID (WHAM) Women's Health and Mindfulness Program- Group Intervention Screening Questionnaire.docx	No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	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.