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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Instrument 1 CHaRMED Program Visit Screener.docx	Other-Screener

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:

table that charts list of 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 %

table that charts list of burden
	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

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.