Information Collection

Eligibility Screener

IC 235193 under ICR 202106-0920-005 · OMB 0920-1266.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screener	Form and Instruction
ChiCAS Screener - English Eligibility Screener	Form and Instruction
ChiCAS Screener - Spanish Eligibility Screener	Form and Instruction
ChiCAS Screener - English Eligibility Screener	Form and Instruction
ChiCAS Screener - Spanish Eligibility Screener	Form and Instruction
Form 0920-1266 ChiCAS Eligibility Screener - English JUN2021 Eligibility Screener	Form and Instruction
Form 0920-1266 ChiCAS Eligibility Screener - Spanish JUN2021 Eligibility Screener	Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx	Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English.docx	Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc	Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish.doc	Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf	Form and Instruction
ChiCAS Screener - English Att 4a_ChiCAS Screener English_30APR2019.pdf	Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	Form and Instruction
ChiCAS Screener - Spanish Att 4b_ChiCAS Screener Spanish_30APR2019.pdf	Form and Instruction
0920-1266 ChiCAS Eligibility Screener - English JUN2021 Att 4a_ChiCAS Screener and Contact English.docx	Form and Instruction
0920-1266 ChiCAS Eligibility Screener - English JUN2021 Att 4a_ChiCAS Screener and Contact English.docx	Form and Instruction
0920-1266 ChiCAS Eligibility Screener - Spanish JUN2021 Att 4b_ChiCAS Screener and Contact Spanish.docx	Form and Instruction
0920-1266 ChiCAS Eligibility Screener - Spanish JUN2021 Att 4b_ChiCAS Screener and Contact Spanish.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Eligibility Screener

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.	URL	Available Electronically?	Electronic Capability
Form and Instruction	NA	NA	No	Paper Only
Form and Instruction	NA	NA	No	Paper Only
Form and Instruction	NA	NA	No	Paper Only
Form and Instruction	NA	NA	No	Paper Only
Form and Instruction	0920-1266	NA	No	Paper Only
Form and Instruction	0920-1266	NA	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 140

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	140	140
Annual IC Time Burden (Hours)	7	7
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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