Information Collection

Screener

IC 215651 under ICR 201503-0910-008 · OMB 0910-0790.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A--Initial Contact Letter with Screener.doc	Other-Contact Letter with Screener
Attachment B--Consent Form In Person.doc	Other-Consent Form
Attachment C--Follow-Up Letter.doc	Other-Follow up letter

IC Title:

Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Contact Letter with Screener	Attachment A--Initial Contact Letter with Screener.doc	No	Printable Only
Other-Consent Form	Attachment B--Consent Form In Person.doc	No	Printable Only
Other-Follow up letter	Attachment C--Follow-Up Letter.doc	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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