Information Collection

Alcohol Consumption Focus Group Screener

IC 224798 under ICR 201612-0920-006 · OMB 0920-1179.

Documents and Forms

Document Name Document Type
Attachment C- Screener_112316.docx Other-WORD
Attachment D- Consent Form_112316.docx Att D_ Informed Consent Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Alcohol Consumption Focus Group Screener	Agency IC Tracking Number:	16AUE

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-WORD			Attachment C- Screener_112316.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 288	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	288	288
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D_ Informed Consent Form	Attachment D- Consent Form_112316.docx	12/12/2016

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