Information Collection

2024 NSECE Center-based Provider Screener and Questionnaire

IC 259978 under ICR 202309-0970-011 · OMB 0970-0391.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0391 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 3 2024 NSECE Center-based Provider Screener and Questionnaire_toOPRE_092123.docx	Other-Screener and Questionnaire (En
Instrument 3 2024 NSECE Center-based Provider Screener and Questionnaire_toOPRE_092123.docx	Other-Screener and Questionnaire (En
Instrument 3S 2024 NSECE Center-based Provider Screener and Questionnaire (Spanish)_toOPRE_092123.docx	Other-Screener and Questionnaire (Sp
Instrument 3S 2024 NSECE Center-based Provider Screener and Questionnaire (Spanish)_toOPRE_092123.docx	Other-Screener and Questionnaire (Sp

IC Title:

2024 NSECE Center-based Provider Screener and Questionnaire

Agency IC Tracking Number:

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
Other-Screener and Questionnaire (English)			Instrument 3 2024 NSECE Center-based Provider Screener and Questionnaire_toOPRE_092123.docx		Yes	Yes	Fillable Fileable
Other-Screener and Questionnaire (Spanish)			Instrument 3S 2024 NSECE Center-based Provider Screener and Questionnaire (Spanish)_toOPRE_092123.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,392

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	Previously Approved
Annual Number of Responses for this IC	8,392	8,392
Annual IC Time Burden (Hours)	6,294	6,294
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.