Information Collection

U.S. Effects Screening Questionaire

IC 213878 under ICR 201411-3420-004 · OMB 3420-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3420-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OPIC-252 U.S. Effects Screening Questionaire	Form
OPIC-252 US Effects Screening Questionaire OPIC 252 - Supporting Statement [FINAL 150108].docx	Form
OPIC 252 - Form 83 I_signed.pdf I-83	IC Document

IC Title:

U.S. Effects Screening Questionaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR 706

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	OPIC-252	US Effects Screening Questionaire	OPIC 252 - Supporting Statement [FINAL 150108].docx		Yes	Yes	Fillable Fileable Signable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	200	200
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	15,000	15,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
I-83	OPIC 252 - Form 83 I_signed.pdf	11/13/2014

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