Information Collection

Screener Verification

IC 216268 under ICR 201804-0920-011 · OMB 0920-0314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener Verification	Form
Screener Verification ATT_L2 _Screener Verification 091917.doc	Form
ATT_L1_VerificationQues Descrip 040918.doc Verfification Questionnaire Description	IC Document

IC Title:

Screener Verification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Screener Verification	ATT_L2 _Screener Verification 091917.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 1,500

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	Previously Approved
Annual Number of Responses for this IC	1,500	0	1,500
Annual IC Time Burden (Hours)	50	0	50
Annual IC Cost Burden (Dollars)	1,320	1,320	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Verfification Questionnaire Description	ATT_L1_VerificationQues Descrip 040918.doc	04/25/2018

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