Information Collection

Screening and Consent

IC 217186 under ICR 202209-0920-012 · OMB 0920-1083.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1083 Screening and Consent	Form and Instruction
Form 0920-1083 Screening and Consent Screening and Consent	Form and Instruction
0920-1083 Screening and Consent Attachment C. Screening & Consent Questionaire Screenshots.pdf	Form and Instruction
0920-1083 Screening and Consent Attachment C. Screening & Consent Questionaire Screenshots.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1083

Is this a Common Form? No

IC Status: Modified

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	0920-1083				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,667

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	Previously Approved
Annual Number of Responses for this IC	16,667	16,667
Annual IC Time Burden (Hours)	1,389	1,389
Annual IC Cost Burden (Dollars)	32,501	32,501

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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