View Information Collection (IC)

View Information Collection (IC)

IC Title:	Household Screener	Agency IC Tracking Number:

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
Form and Instruction	3	Household Screening Questionnaire	NSFG 2009 ATTACH G4--Screener.doc		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164	FR Citation: 49 FR 37693

Number of Respondents: 14,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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	14,000	0	0	0	0	14,000
Annual IC Time Burden (Hours)	700	0	0	0	0	700
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
NSFG 2009 ATT G3-ConsentForms	NSFG 2009 ATT G3-ConsentForms.doc	03/31/2009
NSFG 2009 G2a -QA Brochure	NSFG 2009 G2a -QA Brochure.pdf	03/31/2009
NSFG 2009 G2b-Confidentiality	NSFG 2009 G2b-Confidentiality.pdf	03/31/2009

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