Information Collection

Individual Screening

IC 233938 under ICR 201811-2127-003 · OMB 2127-0742.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1461 Individual Screening	Form and Instruction
1461 Individual level screening form Form 1461-ClinicianLevelEmailPhoneScreeningForm.docx	Form and Instruction

IC Title:

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	1461	Individual level screening form	Form 1461-ClinicianLevelEmailPhoneScreeningForm.docx		No		Paper Only

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	3,000	3,000
Annual IC Time Burden (Hours)	250	250
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.