Information Collection

Household Eligibility Screener

IC 233850 under ICR 202001-0923-004 · OMB 0923-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0059 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Household Eligibility Screener	Form
Household Eligibility Screener PrtApndxA3_HHEligibilityScreener 20190206_clean.docx	Form
PrtApndxA2_HHRecrtmntlttr and Fact Sheets 20190206_clean.docx Household Eligibility Recruitment Letter and Fact Sheet	IC Document

IC Title:

Household Eligibility Screener

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	NA	Household Eligibility Screener	PrtApndxA3_HHEligibilityScreener 20190206_clean.docx	NA	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: 1,345

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	1,345	1,345
Annual IC Time Burden (Hours)	112	112
Annual IC Cost Burden (Dollars)	2,730	2,730

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Household Eligibility Recruitment Letter and Fact Sheet	PrtApndxA2_HHRecrtmntlttr and Fact Sheets 20190206_clean.docx	06/27/2019

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