Information Collection

Eligibility Survey

IC 227799 under ICR 201708-0920-006 · OMB 0920-1203.

Documents and Forms

Document Name Document Type
Eligibility Survey Form
BITM Eligibility Survey Attachment C_Eligibility survey.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eligibility Survey	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	BITM Eligibility Survey	Attachment C_Eligibility survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 125	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	125	125
Annual IC Time Burden (Hours)	31	31
Annual IC Cost Burden (Dollars)	746	746

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.