Information Collection

Screening and Consent (English and Spanish)

IC 217186 under ICR 201909-0920-005 · OMB 0920-1083.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1083 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1083 Screening and Consent (English and Spanish)	Form and Instruction
0920-1083 Screening and Consent Attachment C-1. Screening & Consent Screenshots 12-5-18 (English).pdf	Form and Instruction
0920-1083 Screener and Consent Spanish Attachment C-2. Screening & Consent Screenshots 6-10-19 (Spanish).pdf	Form and Instruction

IC Title:

Screening and Consent (English and Spanish)

Agency IC Tracking Number:

15PI

Is this a Common Form? No

IC Status: Modified

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	0920-1083	Screener and Consent Spanish	Attachment C-2. Screening & Consent Screenshots 6-10-19 (Spanish).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1083	Screening and Consent	Attachment C-1. Screening & Consent Screenshots 12-5-18 (English).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,667

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,667	-8,333	25,000
Annual IC Time Burden (Hours)	1,389	-694	2,083
Annual IC Cost Burden (Dollars)	32,501	-16,249	48,750

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.