2019 Generic Screener with UYC Pilot Screener

Generic Clearance for Questionnaire Pretesting Research

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0725 can be found here:

Documents and Forms

Document Name Document Type
Form 1 2019 Generic Screener with UYC Pilot Screener Form
1 Screeners part A and part B Screener Parts A and B.docx Form
Screener OMB Memo.docx Memo IC Document

Information Collection (IC) Details

IC Title:	2019 Generic Screener with UYC Pilot Screener	Agency IC Tracking Number:

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	1	Screeners part A and part B	Screener Parts A and B.docx		No		Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500	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	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Memo	Screener OMB Memo.docx	11/01/2018

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