Information Collection

App C_Recruitment Web Screener

IC 219904 under ICR 201601-0920-018 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Document Name Document Type
App C_ Web Survey Screener_ (screenshots).docx Other-Screenshots
App C1_ Web Survey Screener.docx App C1_Web Survey Screener (WORD) IC Document
App A_Recruitment Flyer.doc App A_recruitment Flyer IC Document
App B_Recruitment Adv.docx App B_Recruitment Advertisements IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	App C_Recruitment Web Screener	Agency IC Tracking Number:	16LV

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
Other-Screenshots			App C_ Web Survey Screener_ (screenshots).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
App C1_Web Survey Screener (WORD)	App C1_ Web Survey Screener.docx	01/29/2016
App A_recruitment Flyer	App A_Recruitment Flyer.doc	01/29/2016
App B_Recruitment Advertisements	App B_Recruitment Adv.docx	01/29/2016

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