Information Collection

Community Screener - Screened Injection Drug Users and High-risk heterosexual individuals

IC 200567 under ICR 201112-0920-015 · OMB 0920-0922.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0922 can be found here:

Documents and Forms

Document Name Document Type
Rev Attach 3a Eligibility Screener-Community Survey.docx Instruction
Attach 7b _Venue Owner_Manager Script.doc Attachment 7b Venue Owner Script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Community Screener - Screened Injection Drug Users and High-risk heterosexual individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Instruction			Rev Attach 3a Eligibility Screener-Community Survey.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 7b Venue Owner Script	Attach 7b _Venue Owner_Manager Script.doc	12/20/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.