Information Collection

Verification of Participant Eligibility

IC 226273 under ICR 201702-0920-009 · OMB 0920-1209.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1209 can be found here:

Documents and Forms

Document Name Document Type
Verification of Participant Eligibility Form
Participant Screening Att 4a_Participant Screening Form_02-15-2017.docx Form
Screenshots of the Screening Form Att 4g_M-Cubed P2 Screening Form Screenshots.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Verification of Participant Eligibility	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	N/A	Participant Screening	Att 4a_Participant Screening Form_02-15-2017.docx		Yes	Yes	Fillable Fileable
Form	N/A	Screenshots of the Screening Form	Att 4g_M-Cubed P2 Screening Form Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 635	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	635	635
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	984	984

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.