Information Collection

Screening and Consent

IC 200737 under ICR 201411-0920-011 · OMB 0920-0923.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening and Consent	Form
Screening Questionnaire - Spanish Screenshots Attachment C-1 (Screenshots Spanish) 2-6-14.pdf	Form
Screening Questionnaire - screenshots Attachment C-1 (Screenshots) 2-6-14.pdf	Form
Attachment C-1 (Spanish) 2-6-14.doc Screening Questionnaire - Spanish	IC Document
Attachment C-1 Screening Questionnaire 2-6-14 (FINAL).docx Screening Questionnaire - Word	IC Document

IC Title:

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	Screening Questionnaire - Spanish Screenshots	Attachment C-1 (Screenshots Spanish) 2-6-14.pdf		Yes	Yes	Fillable Fileable
Form	none	Screening Questionnaire - screenshots	Attachment C-1 (Screenshots) 2-6-14.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,074

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	Previously Approved
Annual Number of Responses for this IC	13,074	13,074
Annual IC Time Burden (Hours)	1,090	1,090
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screening Questionnaire - Spanish	Attachment C-1 (Spanish) 2-6-14.doc	02/10/2014
Screening Questionnaire - Word	Attachment C-1 Screening Questionnaire 2-6-14 (FINAL).docx	02/10/2014

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