Information Collection

BABI Screener Questionnaire

IC 219639 under ICR 201601-0920-012 · OMB 0920-1115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1115 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-15BEB BABI Screener Questionnaire Form and Instruction
Attachment 12_BAB_Flyers&Brochure.pdf Instruction
0920-15BEB Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0 Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0.docx Form and Instruction
15BEB Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0 Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	BABI Screener Questionnaire	Agency IC Tracking Number:	15BEB

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	Available Electronically?	Electronic Capability
Form and Instruction	0920-15BEB	Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0	Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0.docx	No	Fillable Printable
Form and Instruction	15BEB	Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0	Attachment 2s_BABI_ScreenerQuestionnaire_SPAN_V1.0.docx	No	Fillable Printable
Instruction			Attachment 12_BAB_Flyers&Brochure.pdf	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 98	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	98	98
Annual IC Time Burden (Hours)	13	13
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.