Information Collection

Augmentation Screener

IC 191115 under ICR 201510-0930-004 · OMB 0930-0106.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0106 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Augmentation scree Augmentation Screener	Form and Instruction
Augmentation scree Augmentation screener Attachment A3- Augmentation screener questionnaire.docx	Form and Instruction

IC Title:

Augmentation Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Augmentation screener	Augmentation screener	Attachment A3- Augmentation screener questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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)	160	160
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.