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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 1 Telephone Screener	Form and Instruction
1 Attachment B Telephone Screener AttachB_TelephoneScreener.docx	Form and Instruction

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:

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	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 %

table that charts list of burden
	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

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.