Information Collection

Phase II - Baseline Form

IC 191373 under ICR 201001-0920-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 II - Baseline Form	Form and Instruction
1 Phase 1 Section Foreman Form Attachment 6 - Phase I Section Foreman Form.doc	Form and Instruction
2 Phase 1 Baseline Form Attachment 7 - Phase I Baseline Form.doc	Form
3 Phase 1 - 1 Month Form Attachment 8 - Phase I 1 month form.doc	Form
4 Phase 1 - Focus Group Questions Attachment 9 - Phase I Focus Group Questions.doc	Form and Instruction
5 Phase II - Section Foreman Form Attachment 10 - Phase II Section Foreman Form.doc	Form
6 Phase II Baseline Form Attachment 11 - Phase II Baseline Form.doc	Form

IC Title:

Phase II - Baseline Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Phase 1 Section Foreman Form	Attachment 6 - Phase I Section Foreman Form.doc	No	No	Paper Only
Form	2	Phase 1 Baseline Form	Attachment 7 - Phase I Baseline Form.doc	No	No	Paper Only
Form	3	Phase 1 - 1 Month Form	Attachment 8 - Phase I 1 month form.doc	No	No	Paper Only
Form and Instruction	4	Phase 1 - Focus Group Questions	Attachment 9 - Phase I Focus Group Questions.doc	No	No	Paper Only
Form	5	Phase II - Section Foreman Form	Attachment 10 - Phase II Section Foreman Form.doc	No	No	Paper Only
Form	6	Phase II Baseline Form	Attachment 11 - Phase II 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: 54

Number of Respondents for Small Entity: 6

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	54	54
Annual IC Time Burden (Hours)	18	18
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.