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Individuals Screened/Coginitive testing
Facts for Consumers About Health
OMB: 0955-0002
IC ID: 189373
OMB.report
HHS/ONC
OMB 0955-0002
ICR 201211-0955-001
IC 189373
( )
Documents and Forms
Document Name
Document Type
Attachment B OMB 0955-0002.docx
Other-telephone script
Attachment D OMB 0955-0002.docx
Other-testing
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Individuals Screened/Coginitive testing
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
Other-telephone script
Attachment B OMB 0955-0002.docx
No
No
Paper Only
Other-testing
Attachment D OMB 0955-0002.docx
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
104
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
104
0
20
0
84
0
Annual IC Time Burden (Hours)
26
0
5
0
21
0
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.