Information Collection

Quantitative Population Eligibility Screener

IC 255844 under ICR 202503-0920-034 · OMB 0920-1398.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Quantitative Population Eligibility Screener	Form and Instruction
Quantitative Population Eligibility Screener (English) Quantitative Population Eligibility Screener	Form and Instruction
Quantitative Population Eligibility Screener (Spanish) Quantitative Population Eligibility Screener	Form and Instruction
Form 0920-1398 Quantitative Population Eligibility Screener_English_REVISED 27MAR2025 Quantitative Population Eligibility Screener	Form and Instruction
Form 0920-1398 Quantitative Population Eligibility Screener_Spanish_REVISED 27MAR2025 Quantitative Population Eligibility Screener	Form and Instruction
Quantitative Population Eligibility Screener (English) Att 3b_Quantitative Population Eligibility Screener_Eng_20230426_clean.docx	Form and Instruction
Quantitative Population Eligibility Screener (English) Att 3b_Quantitative Population Eligibility Screener_Eng_20230426_clean.docx	Form and Instruction
Quantitative Population Eligibility Screener (Spanish) Att 4b_Quantitative Population Eligibility Screener_Spa_20220921_clean.docx	Form and Instruction
Quantitative Population Eligibility Screener (Spanish) Att 4b_Quantitative Population Eligibility Screener_Spa_20220921_clean.docx	Form and Instruction
0920-1398 Quantitative Population Eligibility Screener_English_REV Att 3b_Quant Population Eligibility Screener_Eng_clean.docx	Form and Instruction
0920-1398 Quantitative Population Eligibility Screener_English_REV Att 3b_Quant Population Eligibility Screener_Eng_clean.docx	Form and Instruction
0920-1398 Quantitative Population Eligibility Screener_Spanish_REV Att 4b_Quant Population Eligibility Screener_Spa_clean.docx	Form and Instruction
0920-1398 Quantitative Population Eligibility Screener_Spanish_REV Att 4b_Quant Population Eligibility Screener_Spa_clean.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Quantitative Population Eligibility Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None		Yes	Yes	Fillable Fileable
Form and Instruction	None		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1398	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1398	N/A	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 76 FR 4458

Number of Respondents: 1,204

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,204	1,204
Annual IC Time Burden (Hours)	100	100
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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