Att 4b_Screener for Men

Developing a Self-Management Tool for Individuals with Systemic Lupus Erythematosus (SLE)

Documents and Forms

Document Name Document Type
Att. 4b - Screener for Men_4 19 2016.docx Other-null

Information Collection (IC) Details

IC Title:	Att 4b_Screener for Men	Agency IC Tracking Number:	16CO

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-null			Att. 4b - Screener for Men_4 19 2016.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.