View Information Collection (IC)
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Women's Health Needs STUDY_SCREENER
Agency IC Tracking Number:
0920-1264-20OZ
Is this a Common Form?
No
IC Status:
Modified
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 Somali translations
Att F2 WHNS Informed Consent Form (Somali translations)_REVISED.docx
No
Paper Only
Other-WORD Arabic translations
Att F4 WHNS Informed Consent Form (Arabic Translations)_REVISED.docx
No
Paper Only
Other-WORD Armharic translations
Att F5 WHNS Informed Consent Form (Amharic Translations)_REVISED.docx
No
Paper Only
Other-WORD Somali translations
Att G2 WHNS_Eligibility Screener (Somali translations)_REVISED.docx
No
Paper Only
Other-WORD Arabic translations
Att G4 WHNS_Eligibility Screener (Arabic translations)_REVISED.docx
No
Paper Only
Other-WORD Armharic translation
Att G5 WHNS_Eligibility Screener (Amharic translations)_REVISED.docx
No
Paper Only
Other-WORD: French translation
Att F3 WHNS Informed Consent Form (French Translations)_NEW.docx
No
Paper Only
Other-WORD: Tigrinya Translation
Att F6 WHNS Informed Consent Form (Tigrinya Translations)_NEW.docx
No
Paper Only
Other-WORD: French Translation
Att G3 WHNS_Eligibility Screener (French translations)_NEW.docx
No
Paper Only
Other-WORD: Tigrinya Translation
Att G6 WHNS_Eligibility Screener (Tigrinya translations)_NEW.docx
No
Paper Only
Other-WORD: Oromo translations
Att G7 Womens Health Needs Study Eligibility Screener (Oromo translations)_NEW.docx
No
Paper Only
Form
none
Consent -English
Att F1 Womens Health Needs Informed Consent Form (English)_Clean.docx
No
Paper Only
Other-WORD - Oromo translation
Att F7 Womens Health Needs Informed Consent Form (Oromo Translations)_NEW.docx.docx
No
Paper Only
Form and Instruction
none
Eligibility Screener
Att G1 Womens Health Needs Study Eligibility Screener (English)_Clean.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,744
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
3,744
0
0
0
0
3,744
Annual IC Time Burden (Hours)
104
0
0
0
0
104
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.