Structured Assessment Case Free Form Query

Technology Clearinghouse National Online Electronic Assessment

Documents and Forms

Document Name Document Type
Form DHS Form 10053 (5/ Structured Assessment Case Free Form Query Form and Instruction
DHS Form 10053 (5/ Structured Assessment Case: Free Form Query Structured Assessment Case Free Form Query.pdf surveys.jsc.eku.edu/mrIWeb/mrIWeb.dll?I.Project=NOEAFREEFORMQUER Form and Instruction

Information Collection (IC) Details

IC Title:	Structured Assessment Case Free Form Query	Agency IC Tracking Number:	DHS Form 10053 (05/08)

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	DHS Form 10053 (5/08)	Structured Assessment Case: Free Form Query	Structured Assessment Case Free Form Query.pdf	http://surveys.jsc.eku.edu/mrIWeb/mrIWeb.dll?I.Project=NOEAFREEFORMQUER	Yes	Yes	Fillable Fileable Signable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	200	200
Annual IC Time Burden (Hours)	100	100
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.