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Information Collection

Physicians Form A Screener Administered on Paper

IC 209864 under ICR 201407-0955-002 · OMB 0955-0015.

Documents and Forms
Document Name
Document Type
Other-survey
Information Collection (IC) Details

View Information Collection (IC)

Physicians Form A Screener Administered on Paper
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-survey 20745_Form A Screener Administered on Paper 120513.docx No No Paper Only

Health Illness Prevention

 

1,571 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,571 0 0 0 0 1,571
Annual IC Time Burden (Hours) 131 0 0 0 0 131
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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