Information Collection

Initial Screening (Refusal)

IC 217699 under ICR 201609-0920-002 · OMB 0920-1005.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Initial Screening (Refusal)	Form and Instruction
Interview Screener - Refusal Attach D Screener Interviewer Refusing.docx	Form and Instruction

IC Title:

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	Interview Screener - Refusal	Attach D Screener Interviewer Refusing.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42484

Number of Respondents: 1,250

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	1,250	-1,250	2,500
Annual IC Time Burden (Hours)	21	-21	42
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.