Information Collection

Eligibility Screening Form _ English

IC 273722 under ICR 202501-0920-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-24FS Eligibility Screening Form _ English	Form
Form 0920-24FS Eligibility Screener English Eligibility Screening Form _ English	Form
0920-24FS Screening Survey English Att 4A_Screener English.docx	Form
0920-24FS Eligibility Screener English Attachment 4A Eligibility Screener_Eng_CLEAN.docx	Form

IC Title:

Agency IC Tracking Number:

0920-24FS

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	0920-24FS				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,400

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	5,400	5,400
Annual IC Time Burden (Hours)	450	450
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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