Information Collection

Alcohol Consumption Focus Group Screener

IC 224798 under ICR 201612-0920-006 · OMB 0920-1179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment C- Screener_112316.docx	Other-WORD
Attachment D- Consent Form_112316.docx Att D_ Informed Consent Form	IC Document

IC Title:

Agency IC Tracking Number:

16AUE

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					No		Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 288

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	288	288
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D_ Informed Consent Form		12/12/2016

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

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