Information Collection

Women's Health Needs STUDY_SCREENER

IC 234870 under ICR 202006-0920-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 WHNS Informed Consent Form (Somali translations)_REVISED.docx	Other-WORD Somali translations
Att F4 WHNS Informed Consent Form (Arabic Translations)_REVISED.docx	Other-WORD Arabic translations
Att F5 WHNS Informed Consent Form (Amharic Translations)_REVISED.docx	Other-WORD Armharic translations
Att G2 WHNS_Eligibility Screener (Somali translations)_REVISED.docx	Other-WORD Somali translations
Att G4 WHNS_Eligibility Screener (Arabic translations)_REVISED.docx	Other-WORD Arabic translations
Att G5 WHNS_Eligibility Screener (Amharic translations)_REVISED.docx	Other-WORD Armharic translation
Att F3 WHNS Informed Consent Form (French Translations)_NEW.docx	Other-WORD: French translation
Att F6 WHNS Informed Consent Form (Tigrinya Translations)_NEW.docx	Other-WORD: Tigrinya Translation
Att G3 WHNS_Eligibility Screener (French translations)_NEW.docx	Other-WORD: French Translation
Att G6 WHNS_Eligibility Screener (Tigrinya translations)_NEW.docx	Other-WORD: Tigrinya Translation
0920-1264 Women's Health Need STUDY_ Eligibility Screener Att G1 WHNS Eligibility Screener (English)_revised 060220.docx	Form and Instruction

IC Title:

Women's Health Needs STUDY_SCREENER

Agency IC Tracking Number:

0920-1264-20OZ

Is this a Common Form? No

IC Status: Modified

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: French translation			Att F3 WHNS Informed Consent Form (French Translations)_NEW.docx	No	Paper Only
Other-WORD: Tigrinya Translation			Att F6 WHNS Informed Consent Form (Tigrinya Translations)_NEW.docx	No	Paper Only
Other-WORD: French Translation			Att G3 WHNS_Eligibility Screener (French translations)_NEW.docx	No	Paper Only
Other-WORD: Tigrinya Translation			Att G6 WHNS_Eligibility Screener (Tigrinya translations)_NEW.docx	No	Paper Only
Other-WORD			Att F1 Informed Consent_English.docx	No	Paper Only
Other-WORD Somali translations			Att F2 WHNS Informed Consent Form (Somali translations)_REVISED.docx	No	Paper Only
Other-WORD Arabic translations			Att F4 WHNS Informed Consent Form (Arabic Translations)_REVISED.docx	No	Paper Only
Other-WORD Armharic translations			Att F5 WHNS Informed Consent Form (Amharic Translations)_REVISED.docx	No	Paper Only
Form and Instruction	0920-1264	Women's Health Need STUDY_ Eligibility Screener	Att G1 WHNS Eligibility Screener (English)_revised 060220.docx	No	Fillable Fileable
Other-WORD Somali translations			Att G2 WHNS_Eligibility Screener (Somali translations)_REVISED.docx	No	Paper Only
Other-WORD Arabic translations			Att G4 WHNS_Eligibility Screener (Arabic translations)_REVISED.docx	No	Paper Only
Other-WORD Armharic translation			Att G5 WHNS_Eligibility Screener (Amharic translations)_REVISED.docx	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,744

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	Previously Approved
Annual Number of Responses for this IC	3,744	3,077	667
Annual IC Time Burden (Hours)	104	48	56
Annual IC Cost Burden (Dollars)	0	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.