Information Collection

Eligibility Screener

IC 200522 under ICR 201112-0920-011 · OMB 0920-0928.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screener	Form
Screener Att 2a Eligibility Screener.docx	Form
Screener - Spanish version Att 3a Eligibility Screener (Spanish).docx	Form

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	none	Screener	Att 2a Eligibility Screener.docx		Yes	Yes	Fillable Fileable
Form	none	Screener - Spanish version	Att 3a Eligibility Screener (Spanish).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 309,090

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	309,090	309,090
Annual IC Time Burden (Hours)	5,152	5,152
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.