Information Collection

Eligibility Screener

IC 257785 under ICR 202212-0920-002 · OMB 0920-1403.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Eligibility Screener	Form and Instruction
0920 Eligibility Screener Att 3_ Eligibility Screener.docx	Form and Instruction
0920 Eligibility Screener Att 3_ Eligibility Screener.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-22IJ

Is this a Common Form? No

IC Status: New

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	0920	Eligibility Screener	Att 3_ Eligibility Screener.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	104	104
Annual IC Cost Burden (Dollars)	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.