Information Collection

Contact Information Only Questionnaire

IC 191752 under ICR 200912-3045-002 · OMB 3045-0060.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Contact Information Only Questionnaire	Form and Instruction
1 AC Longitudinal Contract Info Phone Questionnaire 4807a Contact Treatment122909.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 1501 et Seq.

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	AC Longitudinal Contract Info Phone Questionnaire	4807a Contact Treatment122909.doc		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,320	3,320
Annual IC Time Burden (Hours)	332	332
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.