Information Collection

Screening Interview with Ineligible Persons

IC 7476 under ICR 200811-0925-002 · OMB 0925-0552.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0552 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Screening Interview with Ineligible Persons	Form and Instruction
1 questionnaire Attachment A Questionnaire.doc	Form and Instruction

IC Title:

Screening Interview with Ineligible Persons

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	questionnaire	Attachment A Questionnaire.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,659

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,659	1,658	1
Annual IC Time Burden (Hours)	50	-350	400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.