Information Collection

Eligibility--Screener

IC 198823 under ICR 201108-0920-003 · OMB 0920-0895.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0895 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Eligibility--Screener	Form and Instruction
1 Eligibility Screener Att 3_Eligibility Screener.pdf	Form and Instruction

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:

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	Eligibility Screener	Att 3_Eligibility Screener.pdf		Yes	Yes	Fillable Printable

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
	Approved	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
No associated records found

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