Information Collection

Screener (Att. K-N )

IC 239167 under ICR 202311-0920-009 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0822 Screener (Att. K-N ) Form and Instruction
0920-0822 Att K_Web_Phone Screeners and Survey Instrument_English Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean.docx Form and Instruction
0920-0822 Att K_Web_Phone Screeners and Survey Instrument_English Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean.docx Form and Instruction
0920-0822 Att N_Paper Screener_Spanish Att N_Paper Screener_Spanish.docx Form and Instruction
0920-0822 Att N_Paper Screener_Spanish Att N_Paper Screener_Spanish.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener (Att. K-N )	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0822	Att K_Web_Phone Screeners and Survey Instrument_English	Att K_Web_Phone Screeners and Survey Instrument_English_REV1.10.23Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0822	Att N_Paper Screener_Spanish	Att N_Paper Screener_Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 48,667	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	48,667	48,667
Annual IC Time Burden (Hours)	4,056	4,056
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.