Screener and questionnaire - round 1

RANDS during COVID19

Documents and Forms

Document Name Document Type
Screener and questionnaire - round 1 Form
Intro screener and questionnaire Att B - Intro Screen and Questionnaire_UPDATED 05 08 2020.docx Form

Information Collection (IC) Details

IC Title:	Screener and questionnaire - round 1	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
Form	none	Intro screener and questionnaire	Att B - Intro Screen and Questionnaire_UPDATED 05 08 2020.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 Probability Samples of the US Population	FR Citation: 49 FR 37693

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
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	4,000	4,000
Annual IC Cost Burden (Dollars)	95,400	95,400

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.