Information Collection

Instrument 1: Screener for selecting fatherhood program visit sites – Screened, not selected for program visit

IC 239031 under ICR 201912-0970-006 · OMB 0970-0540.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0540 can be found here:

Documents and Forms

Document Name Document Type
Instrument 1 CHaRMED Program Visit Screener.docx Other-Screener

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Instrument 1: Screener for selecting fatherhood program visit sites â Screened, not selected for program visit	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-Screener			Instrument 1 CHaRMED Program Visit Screener.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.