Information Collection

Screen and Link

IC 247945 under ICR 202512-0920-007 · OMB 0920-1357.

Documents and Forms

Document Name Document Type
Form 0920-25-0177 Screen and Link Form and Instruction
0920-25-0177 Screen and Link Att 4a Screen and Link_UPDATED.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screen and Link	Agency IC Tracking Number:	0920-25-0177

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-25-0177				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	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	2	2
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.

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