Information Collection

Household Screening

IC 227426 under ICR 201707-0930-003 · OMB 0930-0380.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Screening Question Household Screening	Form and Instruction
Screening Question Screening Questions NMHS OMB_PDF 01.pdf	Form and Instruction
NMHS OMB_PDF 08.pdf Screening Materials	IC Document
Attachment AH NMHS Public Comment.pdf Comment	IC Document
Attachment AI Response to Public Comment.pdf Response	IC Document

IC Title:

Household Screening

Agency IC Tracking Number:

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
Form and Instruction	Screening Questions	Screening Questions	NMHS OMB_PDF 01.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,331

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
Annual Number of Responses for this IC	2,331	2,331
Annual IC Time Burden (Hours)	193	193
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screening Materials	NMHS OMB_PDF 08.pdf	07/10/2017
Comment	Attachment AH NMHS Public Comment.pdf	07/11/2017
Response	Attachment AI Response to Public Comment.pdf	07/11/2017

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