Information Collection

Contact Information

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.