Eligibility Screener

Evaluation of Free Rapid HIV at-home Testing

Documents and Forms

Document Name Document Type
Form form Eligibility Screener Form
form Eligibility Screener Eligibility Screener_screenshot.docx Form
Att 3a Eligibility Screener.docx Eligibility Screener IC Document

Information Collection (IC) Details

IC Title:	Eligibility Screener	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
Form	form	Eligibility Screener	Eligibility Screener_screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24,000	24,000
Annual IC Time Burden (Hours)	1,200	1,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Eligibility Screener	Att 3a Eligibility Screener.docx	03/27/2014

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