Initial Verbal Screening

Factors Influencing the Transmission of Influenza

Documents and Forms

Document Name Document Type
Initial Verbal Screening Form and Instruction
Script for Initial Verbal Screening Attachment 3 - Initial Verbal Screening_2021-2-16.docx Form and Instruction
Script for Initial Verbal Screening Attachment 3 - Initial Verbal Screening_2021-2-16.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Initial Verbal Screening	Agency IC Tracking Number:	0920-0888 (17RT)

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Script for Initial Verbal Screening	Attachment 3 - Initial Verbal Screening_2021-2-16.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	180	0	180
Annual IC Time Burden (Hours)	9	0	9
Annual IC Cost Burden (Dollars)	131	131	0

Documents for IC

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.