Information Collection

Screener

IC 252009 under ICR 202202-0920-001 · OMB 0920-1379.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- Screener	Form and Instruction
0920- Participant Recruitment Scripts & Screener Questions Att 3j Screener.docx	Form and Instruction

IC Title:

Screener

Agency IC Tracking Number:

0920-21HI

Is this a Common Form? No

IC Status: New

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-	Participant Recruitment Scripts & Screener Questions	Att 3j Screener.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 180

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	15	15
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.