Information Collection

Online Screener and Survey

IC 190374 under ICR 201006-0920-005 · OMB 0920-0825.

Documents and Forms

Document Name Document Type
Revised 0920-08AA_Attachment 3F_Online Screener & Survey[15-25].doc Other-online survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Online Screener and Survey	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
Other-online survey			Revised 0920-08AA_Attachment 3F_Online Screener & Survey[15-25].doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	117	50	67
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.