Information Collection

Screening

IC 233910 under ICR 201811-2127-002 · OMB 2127-0736.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1443 Screening	Form and Instruction
1443 Informed Consent Form1443_InformedConsentDocument_v10_7_18_18.docx	Form and Instruction
1444 Wellness Survey Form1444_WellnessSurvey_v9_7_18_18.docx	Form and Instruction

IC Title:

Screening

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	1443	Informed Consent	Form1443_InformedConsentDocument_v10_7_18_18.docx		Yes	Yes	Fillable Fileable Signable
Form and Instruction	1444	Wellness Survey	Form1444_WellnessSurvey_v9_7_18_18.docx		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 85

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	85	85
Annual IC Time Burden (Hours)	85	85
Annual IC Cost Burden (Dollars)	2,288	2,288

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.