Information Collection

Transgender Women > 18 years old - Eligibility Screener

IC 234906 under ICR 201902-0920-007 · OMB 0920-1262.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1262 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
18 years old - Eligibility Screener	Form and Instruction
Eligibility Screener - English Att 5a Eligibility Screener (English).docx	Form and Instruction
Eligibility Screener - Spanish Att 5b Eligibility Screener (Spanish).docx	Form and Instruction

IC Title:

Transgender Women > 18 years old - Eligibility Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Att 5a Eligibility Screener (English).docx	NA	No		Fillable Printable
Form and Instruction	NA	Eligibility Screener - Spanish	Att 5b Eligibility Screener (Spanish).docx	NA	No		Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 990

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	990	990
Annual IC Time Burden (Hours)	83	83
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.