Information Collection

Eligibility Verification

IC 232943 under ICR 201808-0920-015 · OMB 0920-1245.

Documents and Forms

Document Name Document Type
Eligibility Verification Form and Instruction
Verificatgion of Eligibility Att 3b Eligibility Verification.docx Form and Instruction
Att 3g Screener_Beh Assessment Screen Caps.docx Eligibility Verification, Screener & Behavioral Assessment – Print Screens IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Verification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	NA	Verificatgion of Eligibility	Att 3b Eligibility Verification.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Eligibility Verification, Screener & Behavioral Assessment â Print Screens	Att 3g Screener_Beh Assessment Screen Caps.docx	09/24/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.