Information Collection

Eligibility Screening Interview

IC 181809 under ICR 200708-0920-002 · OMB 0920-0760.

Documents and Forms

Document Name Document Type
APPENDIX 6 eligibility interview.doc Other-Eligibility Screening Intervie

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Screening Interview	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

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-Eligibility Screening Interview			APPENDIX 6 eligibility interview.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	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
Annual Number of Responses for this IC	675	675
Annual IC Time Burden (Hours)	113	113
Annual IC Cost Burden (Dollars)	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.