Information Collection

Patient Screener (English/Spanish)

IC 263486 under ICR 202602-0920-002 · OMB 0920-1428.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25AJ Patient Screener (English) Patient Screener (English/Spanish)	Form
Form 0920-25AJ Patient Screener (Spanish) Patient Screener (English/Spanish)	Form
Form 0920-1428 Patient Screener-English_02OCT2025 Patient Screener (English/Spanish)	Form and Instruction
Form 0920-1428 Patient Screener-Spanish_02OCT2025 Patient Screener (English/Spanish)	Form and Instruction
0920-25AJ Patient Screener (English) Att 4a_Patient Screener English_Clean.docx	Form
0920-25AJ Patient Screener (Spanish) Att 4a_Patient Screener Spanish_Clean.docx	Form
0920-1428 Patient Screener-English_02OCT2025 Att 4a_Patient Screener English_CLEAN.docx	Form and Instruction
0920-1428 Patient Screener-Spanish_02OCT2025 Att 4a_Patient Screener Spanish_CLEAN.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1428-25AJ

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-25AJ		Yes	Yes	Fillable Fileable
Form	0920-25AJ		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1428	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1428	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 267

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	267	267
Annual IC Time Burden (Hours)	45	45
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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