Information Collection

Adult - Screener

IC 236639 under ICR 201905-0910-007 · OMB 0910-0880.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0880 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix N HPHC2 Adult Invitation Email_clean.docx	Other-Adult Invitation Email
Appendix J HPHC2 Online Screener_OMBv2 11.20.19_clean.docx	Other-Online Screener

IC Title:

Adult - Screener

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-Adult Invitation Email			Appendix N HPHC2 Adult Invitation Email_clean.docx		Yes	Yes	Fillable Fileable Signable
Other-Online Screener			Appendix J HPHC2 Online Screener_OMBv2 11.20.19_clean.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,400

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	3,400	3,400
Annual IC Time Burden (Hours)	170	170
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.