Information Collection

Screener for Follow-up Assessment of Matter of Balance Programs

IC 188657 under ICR 200904-0920-002 · OMB 0920-0818.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0818 can be found here:

Documents and Forms

Document Name Document Type
Screener for Follow-up Assessment of Matter of Balance Programs Form
Screener for Follow-up Assessment Attachment 2a - Screener for Matter of Balance Evaluation.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener for Follow-up Assessment of Matter of Balance Programs	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
Form	none	Screener for Follow-up Assessment	Attachment 2a - Screener for Matter of Balance Evaluation.doc		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	25	25
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.