Information Collection

Eligibility Screener - Adults 18 or older

IC 232588 under ICR 201901-0920-007 · OMB 0920-1240.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screener - Adults 18 or older	Form and Instruction
Eligibility Screener - English E-1 Eligibility Screener -- English.docx	Form and Instruction
Eligibility Screener - Spanish E-7 Eligibility Screener -- Spanish.docx	Form and Instruction

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 and Instruction	NA	Eligibility Screener - English	E-1 Eligibility Screener -- English.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Eligibility Screener - Spanish	E-7 Eligibility Screener -- Spanish.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 783

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	783	783
Annual IC Time Burden (Hours)	26	26
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.