Information Collection

Screening Part A

IC 179024 under ICR 202601-0920-008 · OMB 0920-0743.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0743 Screening Part A	Form and Instruction
Form 0920-0743 Attachment 4a Screening Part A-English Screening Part A	Form and Instruction
Form 0920-0743 Attachment 4b Screening Part A-Spanish Screening Part A	Form and Instruction
0920-0743 Attachment 4a Screening Part A-English Attachment 4a Screening Part A-English.docx	Form and Instruction
0920-0743 Attachment 4a Screening Part A-English Attachment 4a Screening Part A-English.docx	Form and Instruction
0920-0743 Attachment 4b Screening Part A-Spanish Attachment 4b Screening Part A-Spanish.docx	Form and Instruction
0920-0743 Attachment 4b Screening Part A-Spanish Attachment 4b Screening Part A-Spanish.docx	Form and Instruction

IC Title:

Screening Part A

Agency IC Tracking Number:

0920-0743

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0743				Yes	Yes	Fillable Fileable
Form and Instruction	0920-0743				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 567

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	567	567
Annual IC Time Burden (Hours)	28	28
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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