Information Collection

Adult - Screener

IC 236639 under ICR 202003-0910-009 · OMB 0910-0880.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0880 can be found here:

Documents and Forms

Document Name Document Type
Appendix N HPHC2 Online Survey Adult Invitation Email_CLEAN_3.20.docx Other-Adult Invitation Email
Appendix J HPHC2 Online Survey Screener_CLEAN_3.20.docx Other-Online Screener

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Adult - Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-Online Screener			Appendix J HPHC2 Online Survey Screener_CLEAN_3.20.docx		Yes	Yes	Fillable Fileable Signable
Other-Adult Invitation Email			Appendix N HPHC2 Online Survey Adult Invitation Email_CLEAN_3.20.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,000	8,600	3,400
Annual IC Time Burden (Hours)	600	430	170
Annual IC Cost Burden (Dollars)	0	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.