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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.