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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Questionnaire (pages E5-E27 of the Baseline Questionnaire Form)	Agency IC Tracking Number:

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	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 %

	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

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.