Information Collection

NHBS Screening (All Respondent Groups)

IC 182201 under ICR 201609-0920-008 · OMB 0920-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NHBS Screening (All Respondent Groups)	Form and Instruction
Eligibility Screener (English) Att 3a_Eligibility Screener_Eng.docx	Form and Instruction
Eligibility Screener (Spanish) Att 4a_Eligibility Screener_Span.docx	Form and Instruction

IC Title:

NHBS Screening (All Respondent Groups)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	N/A	Eligibility Screener (English)	Att 3a_Eligibility Screener_Eng.docx		Yes	Yes	Fillable Fileable
Form and Instruction	N/A	Eligibility Screener (Spanish)	Att 4a_Eligibility Screener_Span.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,800

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	Previously Approved
Annual Number of Responses for this IC	13,800	-1,200	15,000
Annual IC Time Burden (Hours)	1,150	-100	1,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.