Information Collection

Individual Screening

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

Documents and Forms

Document Name Document Type
Form 1461 Individual Screening Form and Instruction
1461 Individual level screening form Form 1461-ClinicianLevelEmailPhoneScreeningForm.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual Screening	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.