Information Collection

Instrument 1 - Provider screener

IC 260156 under ICR 202312-0970-009 · OMB 0970-0612.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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
Other-Screener					Yes	Yes	Fillable Fileable
Other-Screener - Spanish					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 %

table that charts list of burden
	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

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.

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