Information Collection

Aim 2.2 Web-based Screener and QUESTIONNAIRE

IC 203731 under ICR 201309-0925-007 · OMB 0925-0669.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Aim 2.2 Web-based Screener and QUESTIONNAIRE	Form and Instruction
1 Web-based Survey MSM_OMB_Attach_2_B_Web-based_Survey_1_2013_V_1.0.pdf	Form and Instruction
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:

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 Survey	MSM_OMB_Attach_2_B_Web-based_Survey_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: 4,800

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	Previously Approved
Annual Number of Responses for this IC	4,800	4,800
Annual IC Time Burden (Hours)	1,584	1,584
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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.