Information Collection

CRF Symptom Screener

IC 257029 under ICR 202310-0920-012 · OMB 0920-1399.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CRF Symptom Screener	Form and Instruction
CRF Symptom Screener Attachment 3_CRF_symptom screener_10-12-22_final.docx	Form and Instruction
CRF Symptom Screener Attachment 3_CRF_symptom screener_10-12-22_final.docx	Form and Instruction
0920-1399 CRF Symptom Screener - Enrollment form, symptom screenin Attachment 3_CRF_symptom screener_10.20.23_CLEAN.docx	Form and Instruction
0920-1399 CRF Symptom Screener - Enrollment form, symptom screenin Attachment 3_CRF_symptom screener_10.20.23_CLEAN.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-22FT

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	n/a	CRF Symptom Screener	Attachment 3_CRF_symptom screener_10-12-22_final.docx		Yes	No	Fillable Fileable
Form and Instruction	0920-1399	CRF Symptom Screener - Enrollment form, symptom screening, and vaccination status 27OCT2023	Attachment 3_CRF_symptom screener_10.20.23_CLEAN.docx	N/A	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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	1,000	1,000
Annual IC Time Burden (Hours)	500	500
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.