Information Collection

Att D-1 Screening Questionnaire

IC 217311 under ICR 201507-0920-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att D-1. Screening & Consent Questionnaire.docx	Other-WORD
Att D-1 Screening & Consent Questionnaire.pdf	Other-Screen Shot

IC Title:

Agency IC Tracking Number:

15MZ

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
Other-WORD			Att D-1. Screening & Consent Questionnaire.docx		Yes	Yes	Fillable Fileable
Other-Screen Shot			Att D-1 Screening & Consent Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	1,667	1,667
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.