Information Collection

Eligibility Screener

IC 237025 under ICR 202003-0920-013 · OMB 0920-1284.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- Eligibility Screener Eligibility Screener	Form and Instruction
0920- Eligibility Screener Att 3b_Registration contact info.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-19BG

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	0920-				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,333

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	3,333	3,333
Annual IC Time Burden (Hours)	111	111
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.

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