Information Collection

Women's Health Needs STUDY_SCREENER

IC 234870 under ICR 202001-0920-016 · OMB 0920-1264.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1264 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att F1 Informed Consent_English.docx	Other-WORD
Att F2 Informed Consent_Somali.docx	Other-WORD Somali translations
Att F3 Informed Consent_Swahili.docx	Other-WORD Swahili translations
Att F4 Informed Consent_Arabic.docx	Other-WORD Arabic translations
Att F5 Informed Consent_Armharic.docx	Other-WORD Armharic translations
Att G2 Initial Pilot Screener WHNS_Somali.docx	Other-WORD Somali translations
Att G3 Initial Pilot Screener WHNS_Swahili.docx	Other-WORD Swahili translations
Att G4 Initial Pilot Screener WHNS_Arabic.docx	Other-WORD Arabic translations
Att G5 Initial Pilot Screener WHNS_Armharic.docx	Other-WORD Armharic translation
0920-18JC Women's Health Need STUDY_Screener Att G1 Initial Pilot Screener WHNS _ENGLISH_09182018.docx	Form and Instruction

IC Title:

Women's Health Needs STUDY_SCREENER

Agency IC Tracking Number:

0920-18JC

Is this a Common Form? No

IC Status: Unchanged

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?	Electronic Capability
Other-WORD			Att F1 Informed Consent_English.docx	No	Paper Only
Other-WORD Somali translations			Att F2 Informed Consent_Somali.docx	No	Paper Only
Other-WORD Swahili translations			Att F3 Informed Consent_Swahili.docx	No	Paper Only
Other-WORD Arabic translations			Att F4 Informed Consent_Arabic.docx	No	Paper Only
Other-WORD Armharic translations			Att F5 Informed Consent_Armharic.docx	No	Paper Only
Form and Instruction	0920-18JC	Women's Health Need STUDY_Screener	Att G1 Initial Pilot Screener WHNS _ENGLISH_09182018.docx	No	Fillable Fileable
Other-WORD Somali translations			Att G2 Initial Pilot Screener WHNS_Somali.docx	No	Paper Only
Other-WORD Swahili translations			Att G3 Initial Pilot Screener WHNS_Swahili.docx	No	Paper Only
Other-WORD Arabic translations			Att G4 Initial Pilot Screener WHNS_Arabic.docx	No	Paper Only
Other-WORD Armharic translation			Att G5 Initial Pilot Screener WHNS_Armharic.docx	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 667

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	667	667
Annual IC Time Burden (Hours)	56	56
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.