Information Collection

Screening Questionnaire

IC 252169 under ICR 202203-0925-002 · OMB 0925-0771.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0771 can be found here:

2022-06-23 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Screening Questionnaire	Form
2 screening questionnaire Attachment 4 Screening Questionnaire.pdf	Form
2 screening questionnaire Attachment 4 Screening Questionnaire.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Screening Questionnaire

Agency IC Tracking Number:

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	2	screening questionnaire	Attachment 4 Screening Questionnaire.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: HHH/NIH/ORS:09-40-0002, Public Health Service (PHS) Commissioned Corps General Personnel Records and OPM/GOVT-10, Employee Medical File System Records.

FR Citation: 81 FR 75138

Number of Respondents: 35,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35,500	35,500
Annual IC Time Burden (Hours)	2,958	2,958
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.