Information Collection

#1 - Baseline Instrument

IC 186736 under ICR 201003-0970-003 · OMB 0970-0360.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0360 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
#1 - Baseline Instrument.doc	Other-#1 - Baseline Instrument

IC Title:

#1 - Baseline Instrument

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
Other-#1 - Baseline Instrument			#1 - Baseline Instrument.doc		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,600

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	Previously Approved
Annual Number of Responses for this IC	3,600	3,550	50
Annual IC Time Burden (Hours)	1,800	1,750	50
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.