Information Collection

Eligibility Screening - Adult/Adolescent Field Users

IC 226774 under ICR 201705-0923-001 · OMB 0923-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0058 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screening - Adult/Adolescent Field Users	Form and Instruction
Field User Eligibility Screening Script Att4b Field User Eligibility Screening Script_Final.docx	Form and Instruction

IC Title:

Eligibility Screening - Adult/Adolescent Field Users

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 and Instruction	none	Field User Eligibility Screening Script	Att4b Field User Eligibility Screening Script_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 41

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
Annual Number of Responses for this IC	41	41
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	25	25

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.