Information Collection

Household Eligibility Screener

IC 233850 under ICR 202206-0923-001 · OMB 0923-0059.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Household Eligibility Screener	Form and Instruction
Household Eligibility Screener PrtApndxA3_HHEligibilityScreener_20220609.docx	Form and Instruction
Household Eligibility Screener PrtApndxA3_HHEligibilityScreener_20220609.docx	Form and Instruction

IC Title:

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	n/a	Household Eligibility Screener	PrtApndxA3_HHEligibilityScreener_20220609.docx		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: 4,560

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	4,560	3,215	1,345
Annual IC Time Burden (Hours)	380	268	112
Annual IC Cost Burden (Dollars)	10,644	7,914	2,730

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.