Information Collection

Cognitive Interview Screener (telephone and mail)

IC 5955 under ICR 201808-0910-007 · OMB 0910-0345.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0345 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0345 Phone Prenotification letter.doc	Other-lettter
0345 Address based mailings.docx	Other-screener

IC Title:

Cognitive Interview Screener (telephone and mail)

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
Other-screener			0345 Address based mailings.docx		Yes	No	Paper Only
Other-lettter			0345 Phone Prenotification letter.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	12	12
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.