Information Collection

Wave One Elligibility Screening Script

IC 234687 under ICR 202110-0923-001 · OMB 0923-0061.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0061 Wave One Elligibility Screening Script	Form and Instruction
Form 0923-0061 Wave One Eligibility Screening Script Wave One Elligibility Screening Script	Form and Instruction
0923-0061 Wave One Eligibility Screening Script P_Att06c WaveOneElgbltyScreeningScript_20200803_clean.docx	Form and Instruction
0923-0061 Wave One Eligibility Screening Script P_Att06c WaveOneElgbltyScreeningScript_20200803_clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	0923-0061				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 612

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	102	102
Annual IC Cost Burden (Dollars)	2,548	2,548

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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