Information Collection

Att 3a_Screener Instrument for In-depth Interviews and Focus Group

IC 224989 under ICR 202106-0920-022 · OMB 0920-1169.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1169 can be found here:

Documents and Forms

Document Name Document Type
Att 3a Screening Instrument-IDI and FG_reinstatement_07-14-20.docx Other-WRD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 3a_Screener Instrument for In-depth Interviews and Focus Group	Agency IC Tracking Number:	0920-21FV

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WRD			Att 3a Screening Instrument-IDI and FG_reinstatement_07-14-20.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,165	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,165	2,165
Annual IC Time Burden (Hours)	72	72
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.