Individual Eligibility Evaluation Form

Disability Qualification Determination

Documents and Forms

Document Name Document Type
IEE INSTRUCTIONS.docx Instruction
3037-0011 Individual Eligibility Eligibility IEE 83I.pdf Form

Information Collection (IC) Details

IC Title:	Individual Eligibility Evaluation Form	Agency IC Tracking Number:	2012-3037-0011

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 41 CFR 51-4.3 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			IEE INSTRUCTIONS.docx		No		Paper Only
Form	3037-0011	Individual Eligibility Eligibility	IEE 83I.pdf		No		Paper Only

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 602	Number of Respondents for Small Entity: 550

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-46,354	46,354
Annual IC Time Burden (Hours)	-386	386
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.