Information Collection

Screener

IC 240023 under ICR 202503-0920-004 · OMB 0920-1316.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25-0033 Screener	Form
Form 0920-25-0033 Screener Screener	Form
0920-25-0033 Screener Att5 Screening-Baseline Survey 20200211 8-14-23 OMB required change CLEAN 2-20-25.docx	Form
0920-25-0033 Screener Att5 Screening-Baseline Survey 20200211 8-14-23 OMB required change CLEAN 2-20-25.docx	Form

IC Title:

Screener

Agency IC Tracking Number:

0920-25-0033

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	0920-25-0033				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Epidemiologic studies and surveillance of disease problems.

FR Citation: 57 FR 62812

Number of Respondents: 84

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 77 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	84	84
Annual IC Time Burden (Hours)	21	21
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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