Information Collection

Screener Screening Form

IC 245496 under ICR 202102-0920-002 · OMB 0920-1346.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1346 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20PM Screener Screening Form	Form and Instruction
0920-20PM Screening Form 2f_screening fields form_clean.docx	Form and Instruction
0920-20PM Screening Form 2f_screening fields form_clean.docx	Form and Instruction

IC Title:

Screener Screening Form

Agency IC Tracking Number:

Is this a Common Form? Yes

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	0920-20PM	Screening Form	2f_screening fields form_clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 301

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	301	301
Annual IC Time Burden (Hours)	3,341	3,341
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.