Information Collection

Screening Verification

IC 227431 under ICR 201707-0930-003 · OMB 0930-0380.

Documents and Forms

Document Name Document Type
Form Screening Verifica Screening Verification Form and Instruction
Screening Verifica Screening Verification Script NMHS OMB_PDF 06.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screening Verification	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 Verification Script	Screening Verification Script	NMHS OMB_PDF 06.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 142	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	142	142
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.