Information Collection

Inital Screening Form

IC 278395 under ICR 202512-0920-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25-0004 Inital Screening Form	Form
Form 0920-25-0004 Attachment C - CDC Initial Screening Form_SAMPLE VHF Inital Screening Form	Form
0920-25-0004 Attachment C - CDC Initial Screening Form_SAMPLE VHF Attachment C - CDC Initial Screening Form_SAMPLE VHF.docx	Form
0920-25-0004 Attachment C - CDC Initial Screening Form_SAMPLE VHF Attachment C - CDC Initial Screening Form_SAMPLE VHF.docx	Form

IC Title:

Agency IC Tracking Number:

0920-25-0004

Is this a Common Form? No

IC Status: New

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	0920-25-0004				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54,750

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54,750	54,750
Annual IC Time Burden (Hours)	4,563	4,563
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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