Information Collection

Transgender Women > 18 years old - Eligibility Screener

IC 234906 under ICR 202202-0920-014 · OMB 0920-1262.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1262 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
18 years old - Eligibility Screener	Form and Instruction
Eligibility Screener (English) Att 4a_Eligibility Screener (English).docx	Form and Instruction
Eligibility Screener (English) Att 4a_Eligibility Screener (English).docx	Form and Instruction
Eligibility Screener (Spanish) Att 5a_Eligibility Screener (Spanish).docx	Form and Instruction
Eligibility Screener (Spanish) Att 5a_Eligibility Screener (Spanish).docx	Form and Instruction

IC Title:

Transgender Women > 18 years old - 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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Eligibility Screener (English)	Att 4a_Eligibility Screener (English).docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Eligibility Screener (Spanish)	Att 5a_Eligibility Screener (Spanish).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 76 FR 4458

Number of Respondents: 1,540

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,540	550	990
Annual IC Time Burden (Hours)	128	45	83
Annual IC Cost Burden (Dollars)	0	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.