Information Collection

Baseline Questionnaire

IC 181529 under ICR 201003-0920-008 · OMB 0920-0761.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no number Baseline Questionnaire	Form
no number Baseline ATTACHMENT E.docx	Form

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	no number	Baseline	ATTACHMENT E.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 0920-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 65

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	65	-1,162	1,227
Annual IC Time Burden (Hours)	16	-332	348
Annual IC Cost Burden (Dollars)	0	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.