Information Collection

Instrument 1 - Provider screener

IC 260156 under ICR 202308-0970-007 · OMB 0970-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0612 can be found here:

Documents and Forms

Document Name Document Type
Instrument 1. Provider screener.docx Other-Screener
Instrument 1. Provider screener.docx Other-Screener
Instrument 1. Provider screener_Spanish.docx Other-Screener - Spanish
Instrument 1. Provider screener_Spanish.docx Other-Screener - Spanish

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Instrument 1 - Provider screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener			Instrument 1. Provider screener.docx		Yes	Yes	Fillable Fileable
Other-Screener - Spanish			Instrument 1. Provider screener_Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.