Information Collection

Adult Proxy Screener - Adults 18 or older

IC 232589 under ICR 201808-0920-003 · OMB 0920-1240.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1240 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult Proxy Screener - Adults 18 or older	Form and Instruction
Adult Proxy Screener - English E-2 Adult-Proxy Screener -- English.docx	Form and Instruction
Adult Proxy Screener - Spanish E-8 Adult-Proxy Screener -- Spanish.docx	Form and Instruction

IC Title:

Adult Proxy Screener - Adults 18 or older

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Adult Proxy Screener - English	E-2 Adult-Proxy Screener -- English.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Adult Proxy Screener - Spanish	E-8 Adult-Proxy Screener -- Spanish.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: 4,250

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
Annual Number of Responses for this IC	4,250	4,250
Annual IC Time Burden (Hours)	992	992
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.