Information Collection

App F_Screening Questionnaire

IC 221621 under ICR 201906-0920-012 · OMB 0920-1125.

Documents and Forms

Document Name Document Type
Appendix F.docx Other-WORD
Appendix K.docx App K_Informed Consent IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	App F_Screening Questionnaire	Agency IC Tracking Number:	16GK

Is this a Common Form? No		IC Status: Unchanged

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
Other-WORD			Appendix F.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
App K_Informed Consent	Appendix K.docx	05/20/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.