Information Collection

Group Intervention Sereening Questionnaire

IC 207858 under ICR 201307-0990-006 · OMB 0990-0414.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey	No	No	Printable Only
Other-Consent	No		Printable Only
Other-ScreenShot	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 %

table that charts list of burden
	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

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.

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