Information Collection

Augmentation Screener

IC 191115 under ICR 202006-0930-001 · OMB 0930-0106.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Augmentation Scree Augmentation Screener	Form and Instruction
Augmentation Scree Augmentation Screener Questionnaire Attachment A3_as of 2020-02-26_Augmentation Screener Questionnaire.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Augmentation Screener Questionnaire	Augmentation Screener Questionnaire	Attachment A3_as of 2020-02-26_Augmentation Screener Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,300

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,300	1,300
Annual IC Time Burden (Hours)	104	104
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.