OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Adult Proxy Screener - Adults 18 or older

IC 232589 under ICR 201901-0920-007 · OMB 0920-1240.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Adult Proxy Screener - Adults 18 or older
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction NA Adult Proxy Screener - English E-2 Adult-Proxy Screener -- English.docx NA Yes Yes Fillable Fileable
Form and Instruction NA Adult Proxy Screener - Spanish E-8 Adult-Proxy Screener -- Spanish.docx NA Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,250 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,250 0 0 0 0 4,250
Annual IC Time Burden (Hours) 992 0 0 0 0 992
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.