OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Eligibility Screening Interview Resfual Questionnaire

IC 181810 under ICR 200708-0920-002 · OMB 0920-0760.

Documents and Forms
Document Name
Document Type
Other-Refusal Questionnaire 6.1
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Eligibility Screening Interview Resfual Questionnaire
 
Yes New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Refusal Questionnaire 6.1 APPENDIX 6 eligibility interview.doc Yes Yes Printable Only

Health Public Health Monitoring

 

90 0
   
Individuals or Households
 
   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 90 0 90 0 0 0
Annual IC Time Burden (Hours) 15 0 15 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Interview Consent APPENDIX 3-3 interview consent.doc 07/23/2007
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.