Information Collection

Field Test Screener

IC 221082 under ICR 201606-0920-009 · OMB 0920-1061.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1061 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Field Test Screener	Form and Instruction
Att 13c-Screener for Field Test_06222016.docx	Other-WORD
Field Test Screener Attachment 13-2016. Field Test Supplement.docx	Form and Instruction

IC Title:

Field Test Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Field Test Screener	Attachment 13-2016. Field Test Supplement.docx		Yes	Yes	Fillable Fileable
Other-WORD			Att 13c-Screener for Field Test_06222016.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 540

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	540	140	400
Annual IC Time Burden (Hours)	134	127	7
Annual IC Cost Burden (Dollars)	0	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.