Contact Information Only Questionnaire

Longitudinal Research on Member Outcomes

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Contact Information Only Questionnaire	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:

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 %

	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

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.