Screener Screening Form

[NCCDPHP] Oral Health Basic Screening Survey for Children

Documents and Forms

Document Name Document Type
Screener Screening Form Form and Instruction
Screening Form 2f_screening fields form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Screener Screening Form	Agency IC Tracking Number:	0920-1346

Is this a Common Form? Yes		IC Status: Modified

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	n/a	Screening Form	2f_screening fields form.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 301	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	301	301
Annual IC Time Burden (Hours)	3,341	3,341
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.