Information Collection

Eligibility Screening Form

IC 235808 under ICR 202106-0923-001 · OMB 0923-0062.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0062 Eligibility Screening Form	Form and Instruction
0923-0062 Eligibility Screener P_AppxN2_FieldUserEligScreen 20210222 cln.docx	Form and Instruction
0923-0062 Eligibility Screener P_AppxN2_FieldUserEligScreen 20210222 cln.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0923-0062

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	0923-0062	Eligibility Screener	P_AppxN2_FieldUserEligScreen 20210222 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.