Information Collection

Phase I Baseline Form

IC 191369 under ICR 200911-0920-006 · OMB 0920-0843.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0843 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Phase I Baseline Form	Form and Instruction
1 Phase I Section Foreman Form Attachment 6 - Phase I Section Foreman Form.doc	Form and Instruction
2 Phase I Baseline Form Attachment 7 - Phase I Baseline Form.doc	Form

IC Title:

Phase I Baseline Form

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	1	Phase I Section Foreman Form	Attachment 6 - Phase I Section Foreman Form.doc		No	No	Paper Only
Form	2	Phase I Baseline Form	Attachment 7 - Phase I Baseline Form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9

Number of Respondents for Small Entity: 1

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9	9
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.