Information Collection

Eligibillity Screener

IC 199161 under ICR 201204-0920-002 · OMB 0920-0925.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibillity Screener	Form
CHATS Attachment K_revised_02272012 CHATS Attachment K_revised_02272012.docx	Form
CHATS Attachment K OMB_EligibScreener_v3.5_Spanish.docx Spanish Screener	IC Document

IC Title:

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	none	CHATS Attachment K_revised_02272012	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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
Spanish Screener	CHATS Attachment K OMB_EligibScreener_v3.5_Spanish.docx	04/16/2012

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