Information Collection

Eligibility Screening

IC 239035 under ICR 202007-0923-001 · OMB 0923-0063.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0063 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0063 Eligibility Screening	Form and Instruction
0923-0063 Eligibility Screening Script M_Att04 ElgbltyScreeningScript_ Clean 23OCT2020.docx	Form and Instruction

IC Title:

Eligibility Screening

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	0923-0063	Eligibility Screening Script	M_Att04 ElgbltyScreeningScript_ Clean 23OCT2020.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: 7,982

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	7,982	7,982
Annual IC Time Burden (Hours)	1,330	1,330
Annual IC Cost Burden (Dollars)	33,231	33,231

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.