Information Collection

A-CASI Baseline

IC 194315 under ICR 201008-0920-009 · OMB 0920-0872.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no number A-CASI Baseline	Form
no number ACASI Quantitative Survey Attachment 3b_Quantitative Survey Measures.07092010.docx	Form
3b Qualitative Survey Measures Attachment 3b_Quantitative Survey Measures11012010.docx	Form

IC Title:

A-CASI Baseline

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	ACASI Quantitative Survey	Attachment 3b_Quantitative Survey Measures.07092010.docx		Yes	Yes	Fillable Fileable
Form	3b	Qualitative Survey Measures	Attachment 3b_Quantitative Survey Measures11012010.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	225	225
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.