Information Collection

Contact Information

IC 235194 under ICR 202106-0920-005 · OMB 0920-1266.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Contact Information	Form and Instruction
Contact Information_ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx	Form and Instruction
Contact Information_ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx	Form and Instruction
Contact Information_ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc	Form and Instruction
Contact Information_ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc	Form and Instruction
Contact Information ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf	Form and Instruction
Contact Information ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf	Form and Instruction
Contact Information ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	Form and Instruction
Contact Information ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	Form and Instruction
0920-1266 ChiCAS Contact Information - English JUN2021 Att 4a_ChiCAS Screener and Contact English.docx	Form and Instruction
0920-1266 ChiCAS Contact Information - English JUN2021 Att 4a_ChiCAS Screener and Contact English.docx	Form and Instruction
0920-1266 ChiCAS Contact Information - Spanish JUN2021 Att 4b_ChiCAS Screener and Contact Spanish.docx	Form and Instruction
0920-1266 ChiCAS Contact Information - Spanish JUN2021 Att 4b_ChiCAS Screener and Contact Spanish.docx	Form and Instruction

IC Title:

Contact Information

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?	Electronic Capability
Form and Instruction	NA	Contact Information_ChiCAS Screener - English	Att 4a_ChiCAS Screener English.docx	NA	No	Paper Only
Form and Instruction	NA	Contact Information_ChiCAS Screener - Spanish	Att 4b_ChiCAS Screener Spanish.doc	NA	No	Paper Only
Form and Instruction	NA	Contact Information ChiCAS Screener - English	Att 4a_ChiCAS Screener English_30APR2019.pdf	NA	No	Paper Only
Form and Instruction	NA	Contact Information ChiCAS Screener - Spanish	Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	NA	No	Paper Only
Form and Instruction	0920-1266	ChiCAS Contact Information - English JUN2021	Att 4a_ChiCAS Screener and Contact English.docx	NA	No	Paper Only
Form and Instruction	0920-1266	ChiCAS Contact Information - Spanish JUN2021	Att 4b_ChiCAS Screener and Contact Spanish.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

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	Previously Approved
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	1	1
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.