Recruitment Screener (English/Spanish)

Study to Estimate Radiation Doses and Cancer Risk From Radioactive Fallout From The Trinity Nuclear Test (NCI)

Documents and Forms

Document Name Document Type
Form 1 Recruitment Screener (English/Spanish) Form
1 screener ATTACHMENT 5 - Screener.docx Form

Information Collection (IC) Details

IC Title:	Recruitment Screener (English/Spanish)	Agency IC Tracking Number:

Is this a Common Form? No		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	screener	ATTACHMENT 5 - Screener.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service	FR Citation: 67 FR 60743

Number of Respondents: 315	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	315	315
Annual IC Time Burden (Hours)	53	53
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.