Information Collection

Screening Interview with Ineligible Persons

IC 7476 under ICR 201208-0925-004 · OMB 0925-0552.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0552 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Screening Interview with Ineligible Persons Form and Instruction
1 Survey Screener Att A NDEP Natl Diab Survey Screener for OMB 22Aug2012 FINAL.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screening Interview with Ineligible Persons	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	1	Survey Screener	Att A NDEP Natl Diab Survey Screener for OMB 22Aug2012 FINAL.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,759	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,759	3,759
Annual IC Time Burden (Hours)	125	125
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.