Information Collection

NHBS Screening (All Respondent Groups)

IC 182201 under ICR 202605-0920-010 · OMB 0920-0770.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0770 Eligibility Screener (English) MAY2026 NHBS Screening (All Respondent Groups)	Form and Instruction
Form 0920-0770 Eligibility Screener (English) MAY2026 NHBS Screening (All Respondent Groups)	Form and Instruction
Form 0920-0770 Eligibility Screener (Spanish) MAY2026 NHBS Screening (All Respondent Groups)	Form and Instruction
Form 0920-0770 Eligibility Screener (Spanish) MAY2026 NHBS Screening (All Respondent Groups)	Form and Instruction
0920-0770 Eligibility Screener (English) MAY2026 Att3a_EligibilityScreener_Eng_2026_28MAY2026.docx	Form and Instruction
0920-0770 Eligibility Screener (English) MAY2026 Att3a_EligibilityScreener_Eng_2026_28MAY2026.docx	Form and Instruction
0920-0770 Eligibility Screener (Spanish) MAY2026 Att4a_EligibilityScreener_Spn_2026_28MAY2026.docx	Form and Instruction
0920-0770 Eligibility Screener (Spanish) MAY2026 Att4a_EligibilityScreener_Spn_2026_28MAY2026.docx	Form and Instruction

IC Title:

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0770			N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0770			N/A	Yes	Yes	Fillable Fileable

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: 57 FR 62811

Number of Respondents: 13,125

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	13,125	625	12,500
Annual IC Time Burden (Hours)	656	-386	1,042
Annual IC Cost Burden (Dollars)	0	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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