Information Collection

Eligibility Screener

IC 186175 under ICR 200808-0920-006 · OMB 0920-0794.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0794 can be found here:

Documents and Forms

Document Name Document Type
Eligibility screener revised.doc Other-Eligibility screener

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Screener	Agency IC Tracking Number:

Is this a Common Form? No		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 screener			Eligibility screener revised.doc		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 240	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	20	20
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.