Information Collection Request

Technology Clearinghouse National Online Electronic Assessment

ICR 200807-1640-001 · OMB 1640-0014 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form DHs Form 10054 (5/ Exit Form Form and Instruction New Available
Form DHS Form 10053 (5/ Structured Assessment Case Free Form Query Form and Instruction New Repair queued
Form DHS Form 10052 (5/ Structured Assessment Case #2 Form and Instruction New Available
Form DHS Form 10051 (5/ Structured Assessment Case #1 Form and Instruction New Available
Form DHS Form 10050 (5/ Entrance Form Form and Instruction New Available
Form DHS Form 10049 (5/ Consent Form Form and Instruction New Available
Supporting Statement B - Tech Clearinghouse.doc Supporting Statement B Uploaded 2008-08-01 Available
Supporting Statement A - Tech Clearinghouse.doc Supporting Statement A Uploaded 2008-08-01 Available
Tech Clearinghouse 30-day notice.pdf Supplementary Document Uploaded 2008-08-01 Available
60-day notice-publication.pdf Supplementary Document Uploaded 2008-07-17 Available
PTA ST Tech Clearinghouse 20070917 PRIV Final.pdf Supplementary Document Uploaded 2008-07-17 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
185981 Exit Form Form and Instruction New
185980 Structured Assessment Case Free Form Query Form and Instruction New
185979 Structured Assessment Case #2 Form and Instruction New
185977 Structured Assessment Case #1 Form and Instruction New
185976 Entrance Form Form and Instruction New
185975 Consent Form Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
10/31/2011 36 Months From Approved
700 0 0
250 0 0
0 0 0





Reginfo record details
6
table that charts list of burden
IC Title Form No. Form Name
Entrance Form DHS Form 10050 (5/08) Entrance Form
Structured Assessment Case #1 DHS Form 10051 (5/08) Structured Assessment Case #1
Structured Assessment Case Free Form Query DHS Form 10053 (5/08) Structured Assessment Case: Free Form Query
Exit Form DHs Form 10054 (5/08) Exit Form
Consent Form DHS Form 10049 (5/08) Consent Form
Structured Assessment Case #2 DHS Form 10052 (5/08) Structured Assessment Case #2

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 700 0 0 700 0 0
Annual Time Burden (Hours) 250 0 0 250 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No