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	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	MI screener	Att4a_MI_ScreenQs_2.15.12.doc		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	Att4a1._MI_Dtrt_AOC_Brochure_20120712.pdf	09/27/2012

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