Information Collection

Qualitative Eligibility Screener

IC 255847 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⚠️ Notice: This information collection may be referencing outdated material.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
Qualitative Eligibility Screener	Form and Instruction
Qualitative Eligibility Screener (English) Att 3e_Qualitative Eligibility Screener_Eng.docx	Form and Instruction
Qualitative Eligibility Screener (Spanish) Att 4e_Qualitative Eligibility Screener_Spa.docx	Form and Instruction

IC Title:

Qualitative 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	Qualitative Eligibility Screener (English)	Att 3e_Qualitative Eligibility Screener_Eng.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Qualitative Eligibility Screener (Spanish)	Att 4e_Qualitative Eligibility Screener_Spa.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: 96

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	96	96
Annual IC Time Burden (Hours)	2	2
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.