Information Collection

Screener (Att. K-N )

IC 239167 under ICR 202503-0920-002 · OMB 0920-0822.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0822 Screener (Att. K-N )	Form and Instruction
Form 0920-0822 Att K_Web_Phone Screeners and Survey Instrument_English Screener (Att. K-N )	Form and Instruction
Form 0920-0822 Att N_Paper Screener_Spanish 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

IC Title:

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	0920-0822				Yes	Yes	Fillable Fileable
Form and Instruction	0920-0822				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 %

table that charts list of burden
	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

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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