Information Collection

Aim 2.1 Web-based SCREENER and Questionnaire

IC 203730 under ICR 201309-0925-004 · OMB 0925-0669.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0669 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Aim 2.1 Web-based SCREENER and Questionnaire	Form and Instruction
1 Web-based Screener MSM_OMB_Attach_2_A_Web-based_Screener_1_2013_V_1.0.pdf	Form and Instruction
MSM_OMB_Attach_2_Web_based_Screener_Q_5_2102_V_3 0 pdf.pdf Web-based Screener and Questionnaire (Screenshots)	IC Document
MSM_OMB_Attach_2_Web-based_Screener_and_Q_8Jan2013_clean_V_4_0.docx MSM_OMB_Attach_2_Web-based_Screener_and_Q_8Jan2013_clean_V_4_0	IC Document

IC Title:

Aim 2.1 Web-based SCREENER and Questionnaire

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	1	Web-based Screener	MSM_OMB_Attach_2_A_Web-based_Screener_1_2013_V_1.0.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Web-based Screener and Questionnaire (Screenshots)	MSM_OMB_Attach_2_Web_based_Screener_Q_5_2102_V_3 0 pdf.pdf	08/15/2012
MSM_OMB_Attach_2_Web-based_Screener_and_Q_8Jan2013_clean_V_4_0	MSM_OMB_Attach_2_Web-based_Screener_and_Q_8Jan2013_clean_V_4_0.docx	01/18/2013

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