Information Collection

Screener

IC 233000 under ICR 202012-0920-018 · OMB 0920-0950.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0950 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener	Form
Screener and Non-response Bias Module Att_3b_Screener Instrument rev 102318.docx	Form
Screener and Non-response Bias Module Att_3b_Screener Instrument rev 102318.docx	Form
Att_3c_Screener Handcards_5_7_2018.docx Screener Hand Cards	IC Document
Att_3c_Screener Handcards_5_7_2018.docx Screener Hand Cards	IC Document

IC Title:

Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Screener and Non-response Bias Module	Att_3b_Screener Instrument rev 102318.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 Probablity Samples of the US Population

FR Citation: 49 FR 37693

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-15,000	15,000
Annual IC Time Burden (Hours)	-1,250	1,250
Annual IC Cost Burden (Dollars)	-29,850	29,850

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screener Hand Cards	Att_3c_Screener Handcards_5_7_2018.docx	09/13/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.