Information Collection

A-CASI Baseline

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.