Information Collection

Screener

IC 240023 under ICR 202307-0920-001 · OMB 0920-1316.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1316 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screener	Form
Screener	Form
Survey screener Att5 Screening-Baseline Survey 20200211.docx	Form
Survey screener Att5 Screening-Baseline Survey 20200211.docx	Form
Screening/Baseline Survey Att5 Screening-Baseline Survey CLEAN 08JAN2021.docx	Form
Screening/Baseline Survey Att5 Screening-Baseline Survey CLEAN 08JAN2021.docx	Form

IC Title:

Screener

Agency IC Tracking Number:

Is this a Common Form? No

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
Form	none	Survey screener	Att5 Screening-Baseline Survey 20200211.docx		No		Paper Only
Form	NA	Screening/Baseline Survey	Att5 Screening-Baseline Survey CLEAN 08JAN2021.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Epidemiologic studies and surveillance of disease problems.

FR Citation: 57 FR 62812

Number of Respondents: 84

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 77 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	84	84
Annual IC Time Burden (Hours)	21	21
Annual IC Cost Burden (Dollars)	512	512

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.