Information Collection

Patient Screening Questionnaire

IC 235656 under ICR 201904-0920-004 · OMB 0920-1267.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patient Screening Questionnaire	Form
Patient Screener 3. Patient Screening Questionnaire.pdf	Form

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	none	Patient Screener	3. Patient Screening Questionnaire.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 84

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	84	84
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	254	254

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.