Information Collection

Screener

IC 233000 under ICR 202001-0920-015 · OMB 0920-0950.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0950 can be found here:

Documents and Forms

Document Name Document Type
Screener Form
Screener and Non-response Bias Module Att_3b_Screener Instrument rev 102318.docx Form
Att_3c_Screener Handcards_5_7_2018.docx Screener Hand Cards IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener	Agency IC Tracking Number:

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
Form	none	Screener and Non-response Bias Module	Att_3b_Screener Instrument rev 102318.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probablity Samples of the US Population	FR Citation: 49 FR 37693

Number of Respondents: 15,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	29,850	29,850

Documents for IC

Title	Document	Date Uploaded
Screener Hand Cards	Att_3c_Screener Handcards_5_7_2018.docx	09/13/2018

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