Eligibility Screener

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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.