Information Collection

Household Screening

IC 43643 under ICR 202501-0930-001 · OMB 0930-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form In-Person Screenin Household Screening	Form and Instruction
Form In-Person Screenin In-Person Screening Questions Household Screening	Form and Instruction
Form Web-based Screenin Web-based Screening Questions Household Screening	Form and Instruction
In-Person Screenin In-Person Screening Questions Attachment T_In-Person Screening Questions_Final 9-30-24.pdf	Form and Instruction
In-Person Screenin In-Person Screening Questions Attachment T_In-Person Screening Questions_Final 9-30-24.pdf	Form and Instruction
Web-based Screenin Web-based Screening Questions Attachment WEB-6_Web-based Screening Questions_Final 9-30-24.pdf	Form and Instruction
Web-based Screenin Web-based Screening Questions Attachment WEB-6_Web-based Screening Questions_Final 9-30-24.pdf	Form and Instruction

IC Title:

Household Screening

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	In-Person Screening Questions				Yes	Yes	Fillable Fileable
Form and Instruction	Web-based Screening Questions				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Alcohol, Drug Abuse, and Mental Health Epidemiologic Data (HHS/SAMHSA/OA)

FR Citation: 84 FR 27341

Number of Respondents: 285,894

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	285,894	285,894
Annual IC Time Burden (Hours)	23,729	23,729
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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