Information Collection

Household Screening

IC 43643 under ICR 201909-0930-001 · OMB 0930-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Screening Form Household Screening	Form and Instruction
Screening Form Screening and Instruction 2020 Main Study_PDF 10_Attachment I.pdf	Form and Instruction
Screening Form Screening and Instruction 2019 NSDUH_PDF 10_attachment I.pdf	Form and Instruction
Redesign Field Tes Redesign Field Test Redesign Field Test_PDF 10_Attachment 10.pdf	Form and Instruction

IC Title:

Household Screening

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Screening Form	Screening and Instruction	2020 Main Study_PDF 10_Attachment I.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Screening Form	Screening and Instruction	2019 NSDUH_PDF 10_attachment I.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Redesign Field Test	Redesign Field Test	Redesign Field Test_PDF 10_Attachment 10.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Alcohol, Drug Abuse, and Mental Health Epidemiologic Data (HHS/SAMHSA/OA)

FR Citation: 84 FR 27341

Number of Respondents: 288,596

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	288,596	151,365	137,231
Annual IC Time Burden (Hours)	71,860	60,469	11,391
Annual IC Cost Burden (Dollars)	0	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.