Information Collection

Initial Verbal Screening

IC 228011 under ICR 202101-0920-010 · OMB 0920-0888.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

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	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 %

table that charts list of burden
	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

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.