View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

[OC] DCPC Screen for Life 0920-0572-24IO
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-0572 Recruitment Language - English Attachment B. Recruitment Language_English_v2.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Recruitment Language - Spanish Attachment C. Recruitment Language_Spanish_v2.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Screener - English_paper Attachment D. Screener_English_paper version.docx N/A No   Paper Only
Form and Instruction 0920-0572 Screener - English_online Attachment E. Screener_English_online version.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Screener - Spanish_paper Attachment F Screener_Spanish_paper version.docx N/A No   Paper Only
Form and Instruction 0920-0572 Screener - Spanish_online Attachment G. Screener_Spanish_online version.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920--0572 Informed Consent - English Attachment H. Informed Consent_English_v2.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Informed Consent - Spanish Attachment I. Informed Consent_Spanish_v2.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Questionnaire-English_paper Attachment J. Questionnaire_English_paper version.docx N/A No   Paper Only
Form and Instruction 0920-0572 Questionnaire-English_online Attachment K. Questionnaire_English_online version.docx N/A Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Questionnaire-Spanish_paper Attachment L. Questionnaire_Spanish_paper version_v2.docx N/A No   Paper Only
Form and Instruction 0920-0572 Questionnaire-Spanish_online Attachment M. Questionnaire_Spanish_online version.docx N/A Yes Yes Fillable Fileable

Health Illness Prevention

 

1,050 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 1,050 0 1,050 0 0 0
Annual IC Time Burden (Hours) 105 0 105 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
List of Attachments Attachment O. List of Attachments_v2.docx 09/03/2024
Background Information Attachment A. Background Information_v2.docx 09/03/2024
DCPC Messages to be Tested Attachment N. List of Messages for Testing_v2.docx 09/03/2024
GenIC Request Memo - HMTS Expedited Review Form HMTSExpeditedReviewForm- Screen for Life 03SEP2024.pdf 09/03/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.