Information Collection

Att 3a_Screener Questions

IC 220112 under ICR 201602-0920-008 · OMB 0920-1134.

Documents and Forms

Document Name Document Type
Att 3a Screener Questions.pdf Other-Screenshots

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 3a_Screener Questions	Agency IC Tracking Number:	16OJ

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			Att 3a Screener Questions.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the US Population	FR Citation: 49 FR 47413

Number of Respondents: 3,000	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	3,000	3,000
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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