Screening Interview

Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) Evaluation

Documents and Forms

Document Name Document Type
Form 1 Screening Interview Form
1 Household Screening Interview for Telephone Interviewing Attachment 2a. Household Screening Interview.doc Form

Information Collection (IC) Details

IC Title:	Screening Interview	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	1	Household Screening Interview for Telephone Interviewing	Attachment 2a. Household Screening Interview.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	14,700	-85,800	100,500
Annual IC Time Burden (Hours)	735	-2,615	3,350
Annual IC Cost Burden (Dollars)	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.