Information Collection

State & Local Agencies

IC 182700 under ICR 201011-0584-003 · OMB 0584-0547.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B.1-State Staff Interview Protocol.doc	Other-Interview - State Staff
Appendix B.2-County Local Interview Protocol.doc	Other-Interview - County Staff
Appendix D-Extant Data Request.doc	Other-Request for Data from Records
Appendix G.1-State Introduction Letter.doc Advance Letter (State Staff)	IC Document
Appendix G.2-County & Local Introduction Letter.doc Advance Letter (County/Local Staff)	IC Document
Appendix J-Introduction Call Scripts.doc Intro Telephone Script	IC Document
Appendix K-Reminder Call Scripts.doc Reminder Telephone	IC Document

IC Title:

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	Instrument File	Available Electronically?	Electronic Capability
Other-Interview - State Staff	Appendix B.1-State Staff Interview Protocol.doc	No	Paper Only
Other-Interview - County Staff	Appendix B.2-County Local Interview Protocol.doc	No	Paper Only
Other-Request for Data from Records	Appendix D-Extant Data Request.doc	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 319

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	331	-641	972
Annual IC Time Burden (Hours)	1,231	-118	1,349
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advance Letter (State Staff)	Appendix G.1-State Introduction Letter.doc	12/06/2010
Advance Letter (County/Local Staff)	Appendix G.2-County & Local Introduction Letter.doc	12/06/2010
Intro Telephone Script	Appendix J-Introduction Call Scripts.doc	06/28/2011
Reminder Telephone	Appendix K-Reminder Call Scripts.doc	06/28/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.