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Screen ing Tool
Doing It For Ourselves (DIFO) Program
OMB: 0990-0412
IC ID: 207814
OMB.report
HHS/HHSDM
OMB 0990-0412
ICR 201307-0990-002
IC 207814
( )
Documents and Forms
Document Name
Document Type
19158_ID App C. Screening Tool (1).docx
Other-screening tool
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Screen ing Tool
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
Other-screening tool
19158_ID App C. Screening Tool (1).docx
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
180
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
180
0
180
0
0
0
Annual IC Time Burden (Hours)
15
0
15
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
