Information Collection

Eligibility Survey

IC 227799 under ICR 201708-0920-006 · OMB 0920-1203.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
BITM Eligibility Survey Eligibility Survey	Form
BITM Eligibility Survey Attachment C_Eligibility survey.pdf	Form

IC Title:

Eligibility Survey

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	none				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

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	125	125
Annual IC Time Burden (Hours)	31	31
Annual IC Cost Burden (Dollars)	746	746

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.

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