Information Collection

Wave Three Eligibility Screening Script

IC 234689 under ICR 201908-0923-001 · OMB 0923-0061.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0061 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Wave Three Eligibility Screening Script	Form and Instruction
Wave Three Eligibility Script P_Att07c WaveTwoorWaveThreeElgbltyScreeningScript_20180802.docx	Form and Instruction

IC Title:

Wave Three Eligibility Screening Script

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Wave Three Eligibility Script	P_Att07c WaveTwoorWaveThreeElgbltyScreeningScript_20180802.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 121

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	121	121
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	756	756

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.