Information Collection

Household Screening

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.