Information Collection

Eligibility Screening Form

IC 235808 under ICR 202012-0923-002 · OMB 0923-0062.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0062 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-19GW Eligibility Screening Form	Form and Instruction
0920-19GW Eligibility Screener 2 - AppxN2_FieldUserEligScreen 20201218 cln.docx	Form and Instruction
0920-19GW Eligibility Screener 2 - AppxN2_FieldUserEligScreen 20201218 cln.docx	Form and Instruction

IC Title:

Eligibility Screening Form

Agency IC Tracking Number:

0923-19GW

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	0920-19GW	Eligibility Screener	2 - AppxN2_FieldUserEligScreen 20201218 cln.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 220

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	220	220
Annual IC Time Burden (Hours)	18	18
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.