Information Collection

Participant disability screening

IC 211959 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Document Name Document Type
Form 1 Participant disability screening Form and Instruction
1 PDE-Participant Disability Screen Eng PDE-Participant Disability Screen_Eng mod Jun 2014.pdf Form and Instruction
PDS-Participant Disability Screen_Span mod June 2014.pdf PDS-Participant Disabilit Screen_ Span IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant disability screening	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 and Instruction	1	PDE-Participant Disability Screen Eng	PDE-Participant Disability Screen_Eng mod Jun 2014.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13,878	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	13,878	13,878
Annual IC Time Burden (Hours)	694	694
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
PDS-Participant Disabilit Screen_ Span	PDS-Participant Disability Screen_Span mod June 2014.pdf	06/23/2014

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