Information Collection

Screener and Consent

IC 217186 under ICR 201506-0920-005 · OMB 0920-1083.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1083 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener and Consent	Form and Instruction
Screening and Consent Questionnaire Att C. Screening & Consent Questionnaire - English and Spanish_061515.pdf	Form and Instruction

IC Title:

Screener and Consent

Agency IC Tracking Number:

15PI

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 and Instruction	none	Screening and Consent Questionnaire	Att C. Screening & Consent Questionnaire - English and Spanish_061515.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	2,083	2,083
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.