Information Collection

Eligibillity Screener

IC 199161 under ICR 201109-0920-001 · OMB 0920-0925.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0925 can be found here:

Documents and Forms

Document Name Document Type
Eligibillity Screener Form
Eligibility Screener CHATS Attachment K_revised_02272012.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibillity Screener	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	Eligibility Screener	CHATS Attachment K_revised_02272012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,118	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	1,118	1,118
Annual IC Time Burden (Hours)	186	186
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.