Information Collection

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

IC 224989 under ICR 202206-0920-015 · OMB 0920-1169.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 3a Screening Instrument-IDI and FG_reinstatement_07-14-20.docx	Other-WRD
Att 3a Screening Instrument-IDI and FG_reinstatement_07-14-20.docx	Other-WRD

IC Title:

Agency IC Tracking Number:

0920-21FV

Is this a Common Form? Yes

IC Status: Unchanged

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
Other-WRD					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 %

table that charts list of burden
	Approved	Previously Approved
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

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.

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