Information Collection

CMEP-RESPECT Eligibility Screener

IC 197244 under ICR 201104-0920-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 CMEP-RESPECT Eligibility Screener	Form and Instruction
3 180-Day Follow-up Att 5c_180-Day Follow-up Survey.pdf	Form and Instruction
4 CMEP-RESPECT Eligibility Screener Att 3_Eligibility Screener.pdf	Form
Att 4_Participation Agreement.pdf Att 4_Participation Agreement	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	3	180-Day Follow-up	Att 5c_180-Day Follow-up Survey.pdf		Yes	Yes	Fillable Fileable
Form	4	CMEP-RESPECT Eligibility Screener	Att 3_Eligibility Screener.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 500

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 4_Participation Agreement	Att 4_Participation Agreement.pdf	04/05/2011

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