Information Collection

Screening and Demographic Questionnaires

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

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.