Information Collection

Eligibility Screener

IC 200522 under ICR 201112-0920-011 · OMB 0920-0928.

Documents and Forms

Document Name Document Type
Eligibility Screener Form
Screener Att 2a Eligibility Screener.docx Form
Screener - Spanish version Att 3a Eligibility Screener (Spanish).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener	Att 2a Eligibility Screener.docx		Yes	Yes	Fillable Fileable
Form	none	Screener - Spanish version	Att 3a Eligibility Screener (Spanish).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 309,090	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	309,090	309,090
Annual IC Time Burden (Hours)	5,152	5,152
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.