Information Collection

Screener and questionnaire - round 1

IC 241593 under ICR 202004-0920-022 · OMB 0920-1298.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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
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 %

table that charts list of burden
	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

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.