Information Collection

Pretest Screener

IC 214029 under ICR 201506-0910-010 · OMB 0910-0784.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0784 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SCREENER DOCUMENT 2-26-2015.docx	Other-Screener document
EMAIL INVITATION 10-28-14.doc	Other-Email Invitation
INFORMED CONSENT FORM 10-28-14.doc	Other-Consent Form
SCALE DEVELOPMENT 30 DAY FRN 10-28-14.doc Scale Development	IC Document

IC Title:

Pretest Screener

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener document	SCREENER DOCUMENT 2-26-2015.docx	Yes	Yes	Printable Only
Other-Email Invitation	EMAIL INVITATION 10-28-14.doc	Yes	Yes	Printable Only
Other-Consent Form	INFORMED CONSENT FORM 10-28-14.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Scale Development	SCALE DEVELOPMENT 30 DAY FRN 10-28-14.doc	11/25/2014

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