Information Collection

Survey Screener Questionnaire

IC 273137 under ICR 202412-0920-014 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23FN Survey Screener Questionnaire	Form
0920-23FN Survey Eligibility Screener Screener 7. Attatchment 4a. Survey Eligibility Screener Screener_Menthol Policy Evaluation.docx	Form
0920-23FN Survey Eligibility Screener Screener 7. Attatchment 4a. Survey Eligibility Screener Screener_Menthol Policy Evaluation.docx	Form

IC Title:

Agency IC Tracking Number:

0920-23FN

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	0920-23FN	Survey Eligibility Screener Screener	7. Attatchment 4a. Survey Eligibility Screener Screener_Menthol Policy Evaluation.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,800	9,800
Annual IC Time Burden (Hours)	327	327
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.