Information Collection

NHBS Screening (All Respondent Groups)

IC 182201 under ICR 201103-0920-003 · OMB 0920-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0770 NHBS Screening (All Respondent Groups)	Form and Instruction
0920-0770 Attachment 3a 0920-0770_Att 3a_Eligibility Screener_Spanish.pdf	Form and Instruction
0920-0770 Attachment 2A 0920-0770_Att 2a_Eligibility Screener_Eng.pdf	Form and Instruction

IC Title:

NHBS Screening (All Respondent Groups)

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	0920-0770	Attachment 3a	0920-0770_Att 3a_Eligibility Screener_Spanish.pdf		Yes	Yes	Fillable Printable
Form and Instruction	0920-0770	Attachment 2A	0920-0770_Att 2a_Eligibility Screener_Eng.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,000	-30,000	45,000
Annual IC Time Burden (Hours)	1,250	-2,500	3,750
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.