Information Collection

Eligibility Screening Survey - Burmese Immigrants and Descendants

IC 226328 under ICR 201801-0923-002 · OMB 0923-0056.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0056 Eligibility Screening Survey - Burmese Immigrants and Descendants	Form and Instruction
0923-0056 Eligibility Screening Survey for Burmese Immigrants and 5d.Eligibility_ScrngSrvy_Burm_20180111_clean.docx	Form and Instruction

IC Title:

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	0923-0056	Eligibility Screening Survey for Burmese Immigrants and their Descendants - 16JAN2018	5d.Eligibility_ScrngSrvy_Burm_20180111_clean.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

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	Previously Approved
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	4	4
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.