Information Collection

Survey Screener

IC 222277 under ICR 201704-2127-002 · OMB 2127-0725.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1321 Survey Screener	Form and Instruction
1321 Survey Screener Appendix A Survey Screener Form 1321 04052017.docx	Form and Instruction

IC Title:

Survey 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	1321	Survey Screener	Appendix A Survey Screener Form 1321 04052017.docx		No		Paper Only

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,416

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	16,416	16,416
Annual IC Time Burden (Hours)	1,368	1,368
Annual IC Cost Burden (Dollars)	31,847	31,847

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.