Information Collection

Resident Focus Group Screening

IC 204450 under ICR 201309-0920-011 · OMB 0920-1004.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Resident Focus Group Screening	Form
Focus Group Screener Att 12A_Focus Group Screening Script.docx	Form
Att 12A-2(e) Other Focus Group Recruitment Materials_9.3.13.docx Focus Group Flyer	IC Document
Att 12A-1_Focus Group Recruitment Flyer.docx Focus Group Flyer	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	Focus Group Screener	Att 12A_Focus Group Screening Script.docx		No	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Focus Group Flyer	Att 12A-2(e) Other Focus Group Recruitment Materials_9.3.13.docx	09/23/2013
Focus Group Flyer	Att 12A-1_Focus Group Recruitment Flyer.docx	09/23/2013

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