Information Collection

Patient Screening Form

IC 206892 under ICR 201404-0915-008 · OMB 0915-0368.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0368 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Screening Form	Form
1 Patient Screener Patient Screening Form41913.doc	Form
Recruitment Script_At Clinic.docx Recruitment Script_At Clinic	IC Document
Flyer.doc Flyer	IC Document
Handout_English.doc Handout_English	IC Document

IC Title:

Patient Screening Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	1	Patient Screener	Patient Screening Form41913.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 92

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-92	92
Annual IC Time Burden (Hours)	-9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Script_At Clinic	Recruitment Script_At Clinic.docx	05/09/2013
Flyer	Flyer.doc	05/09/2013
Handout_English	Handout_English.doc	05/09/2013

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