View Information Collection (IC)

View Information Collection (IC)

IC Title:	Screener Verification	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	none	Screener Verification	ATT_L2 _Screener Verification 091917.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 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 1,500	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	1,500	0	0	0	0	1,500
Annual IC Time Burden (Hours)	50	0	0	0	0	50
Annual IC Cost Burden (Dollars)	1,320	0	1,320	0	0	0

Documents for IC

Title	Document	Date Uploaded
Verfification Questionnaire Description	ATT_L1_VerificationQues Descrip 040918.doc	04/25/2018

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