Information Collection

Verification Quesionnaire for Eligibility Screener (10% subsample)

IC 199170 under ICR 201204-0920-002 · OMB 0920-0925.

Documents and Forms

Document Name Document Type
Verification Quesionnaire for Eligibility Screener (10% subsample) Form
Verification for Screener Attachment P .docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Verification Quesionnaire for Eligibility Screener (10% subsample)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Verification for Screener	Attachment P .docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 112	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	4	4
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.