Information Collection

Prescreener Questionnaire

IC 182459 under ICR 202506-0935-001 · OMB 0935-0110.

Documents and Forms

Document Name Document Type
Form Form #1 Prescreener Questionnaire Form and Instruction
Form Form #1 Precanvass/Prescreener Questionnaire Prescreener Questionnaire Form and Instruction
Form #1 Precanvass/Prescreener Questionnaire Attachment A - Precanvass Questionnaire.pdf Form and Instruction
Form #1 Precanvass/Prescreener Questionnaire Attachment A - Precanvass Questionnaire.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prescreener Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Precanvass/Prescreener Questionnaire	Attachment A - Precanvass Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18,900	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18,900	-6,300	25,200
Annual IC Time Burden (Hours)	1,575	-525	2,100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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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