Information Collection

Eligibility Screening Interview Resfual Questionnaire

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
APPENDIX 6 eligibility interview.doc	Other-Refusal Questionnaire 6.1
APPENDIX 3-3 interview consent.doc Interview Consent	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.