Information Collection

BABI Screener Questionnaire

IC 219639 under ICR 201711-0920-001 · OMB 0920-1115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1115 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-15BEB BABI Screener Questionnaire	Form and Instruction
Attachment 12_BAB_Flyers&Brochure.pdf	Instruction
0920-15BEB Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0 Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0.docx	Form and Instruction
15BEB Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0 Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0.docx	Form and Instruction

IC Title:

BABI Screener Questionnaire

Agency IC Tracking Number:

15BEB

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	0920-15BEB	Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0	Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0.docx	No	Fillable Printable
Form and Instruction	15BEB	Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0	Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0.docx	No	Fillable Printable
Instruction			Attachment 12_BAB_Flyers&Brochure.pdf	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 98

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	Previously Approved
Annual Number of Responses for this IC	98	98
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

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.