Eligibility Screener

[NCHHSTP] Evaluation of Safe Spaces in CDC-directly funded Community-based Organizations (CBOs)

Documents and Forms

Document Name Document Type
Form 0920 Eligibility Screener Form and Instruction
0920 Eligibility Screener Att 3_ Eligibility Screener.docx Form and Instruction
0920 Eligibility Screener Att 3_ Eligibility Screener.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility Screener	Agency IC Tracking Number:	0920-22IJ

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 and Instruction	0920	Eligibility Screener	Att 3_ Eligibility Screener.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	104	104
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.