Information Collection

Baseline Assessment (SUNY)

IC 194333 under ICR 201008-0920-012 · OMB 0920-0873.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0920-10CM_Att3g_BL and FU Assessments (SUNY).docx	Other-WORD
0920-10CM_Att3g_BL and Assessments SUNY 11[1].15.2010-clean.docx	Other-WORD

IC Title:

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
Other-WORD			0920-10CM_Att3g_BL and FU Assessments (SUNY).docx		Yes	Yes	Fillable Printable
Other-WORD			0920-10CM_Att3g_BL and Assessments SUNY 11[1].15.2010-clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

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	80	80
Annual IC Time Burden (Hours)	27	27
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.