Information Collection

Screening/photo form_Screener

IC 262859 under ICR 202309-0920-003 · OMB 0920-1420.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23FJ Screening/photo form_Screener	Form and Instruction
0920-23FJ Attachment 2B_Data collection form B Attachment 2B_Data collection form B.docx	Form and Instruction
0920-23FJ Attachment 2B_Data collection form B Attachment 2B_Data collection form B.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-23FJ

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	0920-23FJ	Attachment 2B_Data collection form B	Attachment 2B_Data collection form B.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6	6
Annual IC Time Burden (Hours)	540	540
Annual IC Cost Burden (Dollars)	56,033	56,033

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.