Information Collection

Quantitative Base Eligibility Screener

IC 255843 under ICR 202305-0920-014 · OMB 0920-1398.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1398 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Quantitative Base Eligibility Screener	Form and Instruction
Quantitative Base Eligibility Screener (English) Att 3a_Quantitative Base Eligibility Screener_Eng_20230426_clean.docx	Form and Instruction
Quantitative Base Eligibility Screener (Spanish) Att 4a_Quantitative Base Eligibility Screener_Spa_20230427_clean.docx	Form and Instruction

IC Title:

Quantitative Base Eligibility Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	Quantitative Base Eligibility Screener (English)	Att 3a_Quantitative Base Eligibility Screener_Eng_20230426_clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Quantitative Base Eligibility Screener (Spanish)	Att 4a_Quantitative Base Eligibility Screener_Spa_20230427_clean.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 HHS/CDC

FR Citation: 76 FR 4458

Number of Respondents: 1,338

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	Previously Approved
Annual Number of Responses for this IC	1,338	1,338
Annual IC Time Burden (Hours)	22	22
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.