Information Collection

MD Screening Tool

IC 266381 under ICR 202501-0920-008 · OMB 0920-1433.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MD Screening Tool	Form and Instruction
MC Screening Tool MD Screening Tool	Form and Instruction
MC Screening Tool Att12_MD5_Screening Tool_03222024.docx	Form and Instruction
MC Screening Tool Att12_MD5_Screening Tool_V2_final.docx	Form and Instruction

IC Title:

MD Screening Tool

Agency IC Tracking Number:

0920-23DV

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	12	12
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.

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