Information Collection

2017 Field Test of Proposed Changes - Screener Only

IC 226396 under ICR 201712-0920-009 · OMB 0920-1061.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1061 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2017 Field Test of Proposed Changes - Screener Only	Form and Instruction
2017 Field Test Screener Only - U.S. General Population Attachment 13c- Screener for 2017 Field Test.docx	Form and Instruction

IC Title:

2017 Field Test of Proposed Changes - Screener Only

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	NA	2017 Field Test Screener Only - U.S. General Population	Attachment 13c- Screener for 2017 Field Test.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-240	240
Annual IC Time Burden (Hours)	-4	4
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.