Information Collection

Household screener (SCREENER ONLY)

IC 232738 under ICR 201808-0970-002 · OMB 0970-0391.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0391 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
15a_2019 NSECE Household Screener and Questionnaire.docx	Other-Screener and Questionnaire
15b_2019 NSECE Household Screener and Questionnaire_Spanish.doc Household Screener and Questionnaire (SPANISH)	IC Document

IC Title:

Household screener (SCREENER ONLY)

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
Other-Screener and Questionnaire			15a_2019 NSECE Household Screener and Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 61,500

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	61,500	61,500
Annual IC Time Burden (Hours)	6,150	6,150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Household Screener and Questionnaire (SPANISH)	15b_2019 NSECE Household Screener and Questionnaire_Spanish.doc	08/20/2018

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