Information Collection

ORCHARDS Phone Screening

IC 212402 under ICR 201512-0920-009 · OMB 0920-1039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1039 can be found here:

Documents and Forms

Document Name Document Type
Att C4- Univ of Wisconsin - Screening Form.docx Other-WORD
Att C5- Univ of Wisconsin - Acute Respiratory Infection and Influenza Surveillance Form.docx Other-WORD
Att D FRN comment.docx Att D - FRN comment IC Document
Att C3- Univ of Wisconsin - consent_assent forms.docx Att C3 Univ of Wisconsin - Consent IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ORCHARDS Phone Screening	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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-WORD			Att C4- Univ of Wisconsin - Screening Form.docx		Yes	Yes	Fillable Printable
Other-WORD			Att C5- Univ of Wisconsin - Acute Respiratory Infection and Influenza Surveillance Form.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies, HHS/CDC.CHPE	FR Citation: 51 FR 42484

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D - FRN comment	Att D FRN comment.docx	07/24/2014
Att C3 Univ of Wisconsin - Consent	Att C3- Univ of Wisconsin - consent_assent forms.docx	07/24/2014

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