Information Collection

Screener

IC 244941 under ICR 202012-0920-010 · OMB 0920-1356.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1356 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener	Form and Instruction
Screener AttachmentI_Screener_Questionnaire.docx	Form and Instruction

IC Title:

Screener

Agency IC Tracking Number:

0920-20QO

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 and Instruction	none	Screener	AttachmentI_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: 2,808

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,808	2,808
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	3,987	3,987

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.