Information Collection

Screening and Demographic Questionnaires

IC 216648 under ICR 201505-0920-004 · OMB 0920-1086.

Documents and Forms

Document Name Document Type
Screening and Demographic Questionnaires Form
Screening/Demographics Attachment I1 - Screening and Demographics Questionnaires.pdf Form
Screenshots of all Survey Instruments Attachment J - Screenshots of All Web-Based Survey Measures.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screening and Demographic Questionnaires	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screening/Demographics	Attachment I1 - Screening and Demographics Questionnaires.pdf		Yes	Yes	Fillable Fileable
Form	none	Screenshots of all Survey Instruments	Attachment J - Screenshots of All Web-Based Survey Measures.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42484

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.