Information Collection

Student Component - ORCHARDS Telephone Screen

IC 212402 under ICR 202108-0920-002 · OMB 0920-1039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1039 Student Component - ORCHARDS Telephone Screen	Form and Instruction
0920-1039 ORCHARDS Screening Form Att. C2 - Screening Form.docx	Form and Instruction
0920-1039 ORCHARDS Screening Form Att. C2 - Screening Form.docx	Form and Instruction
Att D FRN comment.docx Att D - FRN comment	IC Document
Att D FRN comment.docx Att D - FRN comment	IC Document
Att C3- Univ of Wisconsin - consent_assent forms.docx Att C3 Univ of Wisconsin - Consent	IC Document
Att C3- Univ of Wisconsin - consent_assent forms.docx Att C3 Univ of Wisconsin - Consent	IC Document

IC Title:

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	0920-1039	ORCHARDS Screening Form	Att. C2 - Screening Form.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies, HHS/CDC.CHPE

FR Citation: 51 FR 42484

Number of Respondents: 345

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	345	345
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D - FRN comment	Att D FRN comment.docx	07/24/2014
Att C3 Univ of Wisconsin - Consent	Att C3- Univ of Wisconsin - consent_assent forms.docx	07/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.