Information Collection

Screener

IC 198633 under ICR 201201-0920-010 · OMB 0920-0926.

Documents and Forms

Document Name Document Type
Screener Form
Project One Screener Attachment C1_Screener (English)PROJ1Dec9REVISEDFINALcleancopy.doc Form
Spanish Project One Screener Attachment C2_Screener (SPANISH)PROJ1Dec9REVISEDFINALcleancopy.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener	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	none	Project One Screener	Attachment C1_Screener (English)PROJ1Dec9REVISEDFINALcleancopy.doc		Yes	No	Printable Only
Form	none	Spanish Project One Screener	Attachment C2_Screener (SPANISH)PROJ1Dec9REVISEDFINALcleancopy.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 320	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
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	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.