Information Collection

Male Partner Eligibility Questionnaire

IC 223892 under ICR 201610-0920-001 · OMB 0920-1142.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Male Partner Eligibility Questionnaire	Form
Male Partner Eligibility Form Att_B8_Male Partner Eligibility Screening Form 09222106.docx	Form

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	NA	Male Partner Eligibility Form	Att_B8_Male Partner Eligibility Screening Form 09222106.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	417	417
Annual IC Cost Burden (Dollars)	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.