Information Collection

Program Eligibility Protocol

IC 267283 under ICR 202502-0906-002 · OMB 0906-0092.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Program Eligibility Protocol	Form and Instruction
Form 1 Program Eligibility Protocol Program Eligibility Protocol	Form and Instruction
Form 1 Program Eligibility Protocol (Track Changes 07302024) Program Eligibility Protocol	Form and Instruction
1 Program Eligibility Protocol Appendix E_Active Engagement_Instrument1.docx	Form and Instruction
1 Program Eligibility Protocol Appendix E_Active Engagement_Instrument1.docx	Form and Instruction
1 Program Eligibility Protocol (Track Changes 07302024) 0906-0092 1_Program Eligiblity Protocol.docx	Form and Instruction
1 Program Eligibility Protocol (Track Changes 07302024) 0906-0092 1_Program Eligiblity Protocol.docx	Form and Instruction

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
Form and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16

Number of Respondents for Small Entity: 16

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	16	16
Annual IC Time Burden (Hours)	16	16
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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