Information Collection

Baseline Questionnaire (pages E5-E27 of the Baseline Questionnaire Form)

IC 179709 under ICR 200704-0920-001 · OMB 0920-0744.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Baseline Questionnaire (pages E5-E27 of the Baseline Questionnaire Form)	Form and Instruction
Baseline Questionnaire ATTACHMENT E.data collection instrument.doc	Form and Instruction
ATTACHMENT G.introductory letter.doc Introductory Letter	IC Document
ATTACHMENT H.baselinethankyou letter.doc Thank-You for Baseline Participation	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Baseline Questionnaire	ATTACHMENT E.data collection instrument.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 667

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	667	667
Annual IC Time Burden (Hours)	389	389
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Introductory Letter	ATTACHMENT G.introductory letter.doc
Thank-You for Baseline Participation	ATTACHMENT H.baselinethankyou letter.doc

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.