Information Collection

Economic Screening Questionnaire

IC 236749 under ICR 202209-3015-002 · OMB 3015-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3015-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DFC‐012 Economic Screening Questionnaire	Form and Instruction
DFC‐012 Economic Screening Questionnaire DFC-012 - Economic Questionnaire.docx	Form and Instruction
DFC‐012 Economic Screening Questionnaire DFC-012 - Economic Questionnaire.docx	Form and Instruction

IC Title:

Economic Screening Questionnaire

Agency IC Tracking Number:

DFCâ012

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	DFCâ012	Economic Screening Questionnaire	DFC-012 - Economic Questionnaire.docx	N/A	Yes	Yes	Fillable Fileable Signable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	11,250	11,250

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.