Information Collection

Screener and Core Questionnaire

IC 218782 under ICR 201510-0925-005 · OMB 0925-0654.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Attachment 3A Updated Screener and Core Questionnaire Hong-Kong English Screener and Core Questionnaire	Form and Instruction
Form 2 Attachment 3B Updated Screener and Core Questionnaire Hong-Kong Chinese Screener and Core Questionnaire	Form and Instruction
Form 3 Attachment 3C Updated Screener and Core Questionnaire Chengdu-English Screener and Core Questionnaire	Form and Instruction
Form 4 Attachment 3D Updated Screener and Core Questionnaire Chengdu-Chinese Screener and Core Questionnaire	Form and Instruction
Form 5 Attachment 3E Updated Screener and Core Questionnaire Tianjin-English Screener and Core Questionnaire	Form and Instruction
Form 6 Attachment 3F Updated Screener and Core Questionnaire Tianjin-Chinese Screener and Core Questionnaire	Form and Instruction
1 Attachment 3A Updated Screener and Core Questionnaire Ho Attach-3A-Updated-Screener-and-Core-Questionnaire-Hong-Kong-English.doc	Form and Instruction
2 Attachment 3B Updated Screener and Core Questionnaire Ho Attach-3B-Updated-Screener-and-Core-Questionnaire-Hong-Kong-Chinese.doc	Form and Instruction
3 Attachment 3C Updated Screener and Core Questionnaire Ch Attach-3C-Updated-Screener-and-Core-Questionnaire-Chengdu-English.doc	Form and Instruction
4 Attachment 3D Updated Screener and Core Questionnaire Ch Attach-3D-Updated-Screener-and-Core-Questionnaire-Chengdu-Chinese.docx	Form and Instruction
5 Attachment 3E Updated Screener and Core Questionnaire Ti Attach-3E-Updated-Screener-and-Core-Questionnaire-Tianjin-English.doc	Form and Instruction
6 Attachment 3F Updated Screener and Core Questionnaire Ti Attach-3F-Updated-Screener-and-Core-Questionnaire-Tianjin-Chinese.doc	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Screener and Core Questionnaire

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.	Available Electronically?	Electronic Capability
Form and Instruction	1	No	Fillable Fileable
Form and Instruction	2	No	Fillable Fileable
Form and Instruction	3	No	Fillable Fileable
Form and Instruction	4	No	Fillable Fileable
Form and Instruction	5	No	Fillable Fileable
Form and Instruction	6	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,110

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,110	2,110
Annual IC Time Burden (Hours)	176	176
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.

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