Information Collection

Eligibility Screener

IC 262642 under ICR 202310-0920-002 · OMB 0920-1421.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1421 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Eligibility Screener	Form and Instruction
Eligibility Screener Att 4a_Eligibility Screener English.docx	Form and Instruction
Eligibility Screener Att 4a_Eligibility Screener English.docx	Form and Instruction
Eligibility Screener (Spanish) Att 4a_Eligibility Screener Spanish.docx	Form and Instruction
Eligibility Screener (Spanish) Att 4a_Eligibility Screener Spanish.docx	Form and Instruction

IC Title:

Eligibility Screener

Agency IC Tracking Number:

0920-23AQ

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	n/a	Eligibility Screener	Att 4a_Eligibility Screener English.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Eligibility Screener (Spanish)	Att 4a_Eligibility Screener Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 850

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,700	1,700
Annual IC Time Burden (Hours)	142	142
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.