OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Aim 2.1 Web-based SCREENER and Questionnaire

IC 203730 under ICR 201309-0925-007 · OMB 0925-0669.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Aim 2.1 Web-based SCREENER and Questionnaire
 
No Modified
 
Voluntary
 

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

Health Public Health Monitoring

 

2,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,000 0 0 0 0 2,000
Annual IC Time Burden (Hours) 200 0 0 0 0 200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.