Information Collection

Phase 3 - ABS, web screener

IC 239165 under ICR 202105-0920-008 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Phase 3 - ABS, web screener	Form and Instruction
ABS Web screener and survey - English Att F.1_NISVS Web Screener and Survey English_CLEAN.docx	Form and Instruction
ABS Web screener and survey - English Att F.1_NISVS Web Screener and Survey English_CLEAN.docx	Form and Instruction
ABS Web screener and survey - Spanish Att F.1_NISVS Web Screener and Survey Spanish_CLEAN.docx	Form and Instruction
ABS Web screener and survey - Spanish Att F.1_NISVS Web Screener and Survey Spanish_CLEAN.docx	Form and Instruction

IC Title:

Phase 3 - ABS, web screener

Agency IC Tracking Number:

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	none	ABS Web screener and survey - English	Att F.1_NISVS Web Screener and Survey English_CLEAN.docx		Yes	Yes	Fillable Fileable
Form and Instruction	none	ABS Web screener and survey - Spanish	Att F.1_NISVS Web Screener and Survey Spanish_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 278

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	278	251	27
Annual IC Time Burden (Hours)	14	13	1
Annual IC Cost Burden (Dollars)	367	331	36

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.