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Federal forms, ICRs, and supporting documents

Information Collection

Instrument 1 - Provider screener

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

Documents and Forms
Document Name
Document Type
Other-Screener
Other-Screener
Other-Screener - Spanish
Other-Screener - Spanish
Information Collection (IC) Details

View Information Collection (IC)

Instrument 1 - Provider screener
 
No Unchanged
 
Voluntary
 

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

Community and Social Services Social Services

 

120 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 120 0 0 0 0 120
Annual IC Time Burden (Hours) 40 0 0 0 0 40
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.