Information Collection

Survey 1 - Screener Call (Participate/Eligible)

IC 212636 under ICR 201604-0925-003 · OMB 0925-0704.

Documents and Forms

Document Name Document Type
Form 2 Survey 1 - Screener Call (Participate/Eligible) Form and Instruction
2 Claimant Screener Script Survey 1(participate) Attachment 8_Claimant Screener Script Survey 1.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey 1 - Screener Call (Participate/Eligible)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	2	Claimant Screener Script Survey 1(participate)	Attachment 8_Claimant Screener Script Survey 1.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,800	7,800
Annual IC Time Burden (Hours)	1,950	1,950
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.