Information Collection

Att 5_Screening Call Script -- Part B (eligibles only)

IC 189526 under ICR 202108-0920-021 · OMB 0920-0743.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0743 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0743 Att 5_Screening Call Script -- Part B (eligibles only)	Form
0920-0743 Screening Telephone Call to Identify the Appropriate Sur Attachment 4b Screening Call Script_Part B.docx	Form
0920-0743 Screening Telephone Call to Identify the Appropriate Sur Attachment 4b Screening Call Script_Part B.docx	Form
Attachment 5f Reminder Telephone Call Script.docx Reminder Telephone Call Script	IC Document
Attachment 5f Reminder Telephone Call Script.docx Reminder Telephone Call Script	IC Document

IC Title:

Att 5_Screening Call Script -- Part B (eligibles only)

Agency IC Tracking Number:

0920-0743

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	0920-0743	Screening Telephone Call to Identify the Appropriate Survey Contact Person at Eligible Facilities	Attachment 4b Screening Call Script_Part B.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,847

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,847	175	1,672
Annual IC Time Burden (Hours)	123	12	111
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Reminder Telephone Call Script	Attachment 5f Reminder Telephone Call Script.docx	09/29/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.