Information Collection

App F_Screening Questionnaire

IC 221621 under ICR 201605-0920-011 · OMB 0920-1125.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1125 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix F.docx	Other-WORD
Appendix K.docx App K_Informed Consent	IC Document

IC Title:

App F_Screening Questionnaire

Agency IC Tracking Number:

16GK

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
Other-WORD			Appendix F.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	50	50
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
App K_Informed Consent	Appendix K.docx	05/20/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.