Information Collection

Eligibility Screening

IC 232928 under ICR 202010-0920-005 · OMB 0920-1246.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screening	Form
TLC Eligibility Screener Appendix B Eligibility Screener_COVID_21Sept2020_clean.docx	Form

IC Title:

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	n/a	TLC Eligibility Screener	Appendix B Eligibility Screener_COVID_21Sept2020_clean.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 150

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	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	243	243

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.