Information Collection

Initial Participant Screening for Eligibility

IC 226271 under ICR 201804-0920-012 · OMB 0920-1209.

Documents and Forms

Document Name Document Type
Initial Participant Screening for 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:	Initial Participant Screening for Eligibility	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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: 1,693	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,693	1,693
Annual IC Time Burden (Hours)	113	113
Annual IC Cost Burden (Dollars)	2,622	2,622

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.