Information Collection

Screening and Assessment Minimum Data Elements (MDEs)

IC 37802 under ICR 201301-0920-004 · OMB 0920-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 3a ScreeningAssessmentMDE_v800 09 30 2012.docx	Instruction
Attachment 3b Screen Shots of Portal.docx Screenshots of Web Portal	IC Document

IC Title:

Screening and Assessment Minimum Data Elements (MDEs)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			Attachment 3a ScreeningAssessmentMDE_v800 09 30 2012.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	672	672
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screenshots of Web Portal	Attachment 3b Screen Shots of Portal.docx	12/12/2012

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