Information Collection

S4S Screener

IC 254542 under ICR 202207-0930-001 · OMB 0930-0390.

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.