Information Collection

MI Screener

IC 201455 under ICR 201407-0923-001 · OMB 0923-0044.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MI screener MI Screener	Form
MI screener Att4a_MI_ScreenQs_2.15.12.doc	Form
Att4a1._MI_Dtrt_AOC_Brochure_20120712.pdf MI Project Brochure	IC Document

IC Title:

MI Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	none				No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

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
	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MI Project Brochure		09/27/2012

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

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