Information Collection

Patient Eligibility Screener

IC 269818 under ICR 202407-0920-009 · OMB 0920-1438.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1438 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-24CB Patient Eligibility Screener	Form
Form 0920-24CB Patient Eligibility Screener	Form
0920-24CB Patient Eligibility Screener_English Attachment 06a_Pre-Exposure Survey_Eligibility Screener_English.docx	Form
0920-24CB Patient Eligibility Screener_English Attachment 06a_Pre-Exposure Survey_Eligibility Screener_English.docx	Form
0920-24CB Patient Eligibility Screener_Spanish Attachment 06b_Pre-Exposure Survey_Eligibility Screener_Spanish.docx	Form
0920-24CB Patient Eligibility Screener_Spanish Attachment 06b_Pre-Exposure Survey_Eligibility Screener_Spanish.docx	Form
Attachment 06c_Pre-Exposure Survey_Consent Statement_English.docx Consent Statement_English	IC Document
Attachment 06c_Pre-Exposure Survey_Consent Statement_English.docx Consent Statement_English	IC Document
Attachment 06d_Pre-Exposure Survey_Consent Statement_Spanish.docx Consent Statement_Spanish	IC Document
Attachment 06d_Pre-Exposure Survey_Consent Statement_Spanish.docx Consent Statement_Spanish	IC Document

IC Title:

Patient Eligibility Screener

Agency IC Tracking Number:

0920-24CB

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	0920-24CB	Patient Eligibility Screener_English	Attachment 06a_Pre-Exposure Survey_Eligibility Screener_English.docx		Yes	Yes	Fillable Fileable
Form	0920-24CB	Patient Eligibility Screener_Spanish	Attachment 06b_Pre-Exposure Survey_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: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Statement_English	Attachment 06c_Pre-Exposure Survey_Consent Statement_English.docx	08/05/2024
Consent Statement_Spanish	Attachment 06d_Pre-Exposure Survey_Consent Statement_Spanish.docx	08/05/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.