Economic Screening Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3015-0001 can be found here:

Documents and Forms

Document Name Document Type
Form DFC‐012 Economic Screening Questionnaire Form and Instruction
DFC‐012 Economic Screening Questionnaire DFC-012 Economic Questionnaire.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Economic Screening Questionnaire	Agency IC Tracking Number:	DFC‐012

Is this a Common Form? No		IC Status: New

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	DFC‐012	Economic Screening Questionnaire	DFC-012 Economic Questionnaire.pdf	N/A	Yes	Yes	Fillable Fileable Signable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Farms, Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	11,250	11,250

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.