Information Collection

Screening Eligibility Assessment (SEA) Form

IC 185935 under ICR 200807-0935-002 · OMB 0935-0146.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #2 Screening Eligibility Assessment (SEA) Form	Form and Instruction
Form #2 Screening Eligibility Assessment (SEA) Form Attachment C1 -- A Screening Eligibility (SEA) Form.doc	Form and Instruction
Attachment D1 -- Screening Elibility Letter.doc Attachment D1 -- Screening Elibility Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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
Form and Instruction	Form #2	Screening Eligibility Assessment (SEA) Form	Attachment C1 -- A Screening Eligibility (SEA) Form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,500	7,500
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D1 -- Screening Elibility Letter	Attachment D1 -- Screening Elibility Letter.doc	07/25/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.