Information Collection

Interview Baseline

IC 194316 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 Interview Baseline	Form
no number Qualitative Interview Guide Attachment 3c_Qualitative Interview Guide.07092010.docx	Form

IC Title:

Interview 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	Qualitative Interview Guide	Attachment 3c_Qualitative Interview Guide.07092010.docx		Yes	No	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: 0 %

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)	375	375
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.