Information Collection

Eligibility Screener

IC 211027 under ICR 201403-0920-017 · OMB 0920-1018.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.