Information Collection

Verification of Participant Eligibility

IC 226273 under ICR 201804-0920-012 · OMB 0920-1209.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	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 %

table that charts list of burden
	Approved	Previously Approved
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

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.