Information Collection

ORCHARDS Phone Screening

IC 212402 under ICR 201407-0920-005 · OMB 0920-1039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C4- Univ of Wisconsin - Screening Form.docx	Other-WORD
Att C5- Univ of Wisconsin - Acute Respiratory Infection and Influenza Surveillance Form.docx	Other-WORD
Att D FRN comment.docx Att D - FRN comment	IC Document
Att C3- Univ of Wisconsin - consent_assent forms.docx Att C3 Univ of Wisconsin - Consent	IC Document

IC Title:

ORCHARDS Phone Screening

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-WORD			Att C4- Univ of Wisconsin - Screening Form.docx		Yes	Yes	Fillable Printable
Other-WORD			Att C5- Univ of Wisconsin - Acute Respiratory Infection and Influenza Surveillance Form.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies, HHS/CDC.CHPE

FR Citation: 51 FR 42484

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D - FRN comment	Att D FRN comment.docx	07/24/2014
Att C3 Univ of Wisconsin - Consent	Att C3- Univ of Wisconsin - consent_assent forms.docx	07/24/2014

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