Eligibility Screener

Community-based Organization (CBO) Monitoring and Evaluation Project (CMEP) of WILLOW (CMEP-WILLOW)

Documents and Forms

Document Name Document Type
Form 1 Eligibility Screener Form and Instruction
1 Eligibility Screener 0920-New_att3_Eligibility Screener.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	Eligibility Screener	0920-New_att3_Eligibility Screener.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 500

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-500	500
Annual IC Time Burden (Hours)	-17	17
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.