Eligibility Screener

[NCHHSTP] Evaluation of Safe Spaces in CDC-directly funded Community-based Organizations (CBOs)

OMB: 0920-1403

IC ID: 257785

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Eligibility Screener 0920-22IJ
No New

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

Health Public Health Monitoring


1,250 0
Individuals or Households
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,250 0 1,250 0 0 0
Annual IC Time Burden (Hours) 104 0 104 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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