S4S Screener

“Talk. They Hear You.”: Use of “Screen 4 Success” Instruments and Consent form

Documents and Forms

Document Name Document Type
Form S4S Screener S4S Screener Form and Instruction
S4S Screener S4S Screener Attachment A S4S Screener.docx Form and Instruction
S4S Screener S4S Screener Attachment A S4S Screener.docx Form and Instruction

Information Collection (IC) Details

IC Title:	S4S Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	S4S Screener	S4S Screener	Attachment A S4S Screener.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: S4S Screener	FR Citation: 75 FR 28264

Number of Respondents: 100,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	30,000	30,000
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.