Information Collection

Telephone Screener

IC 220183 under ICR 201602-0925-012 · OMB 0925-0739.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0739 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Telephone Screener Form and Instruction
1 Attachment B Telephone Screener AttachB_TelephoneScreener.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Telephone Screener	Agency IC Tracking Number:

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
Form and Instruction	1	Attachment B Telephone Screener	AttachB_TelephoneScreener.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 775	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	775	775
Annual IC Time Burden (Hours)	39	39
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.