Information Collection

Eligibility Screener

IC 235193 under ICR 201902-0920-019 · OMB 0920-1266.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1266 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screener	Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx	Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc	Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf	Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	Form and Instruction

IC Title:

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?	Electronic Capability
Form and Instruction	NA	ChiCAS Screener - Spanish	Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Screener - English	Att 4a_ChiCAS Screener English.docx	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Screener - Spanish	Att 4b_ChiCAS Screener Spanish.doc	NA	No	Paper Only
Form and Instruction	NA	ChiCAS Screener - English	Att 4a_ChiCAS Screener English_30APR2019.pdf	NA	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 140

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	140	140
Annual IC Time Burden (Hours)	7	7
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.