Information Collection

SEBTC - Households

IC 196141 under ICR 201012-0584-005 · OMB 0584-0559.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0559 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A English baseline instrument 3 15 Final.doc	Other-Baseline Questionnaire - Engli
Appendix A Spanish baseline instrument 3 15 11 final.doc	Other-Appendix A :Spanish baseline i
Appendix B English Follow-Up instrument 3 16 11 Final.doc	Other-Appendix B: English Follow-Up
Appendix B Follow-Up questionnaire SPANISH (3-16-11) Final.doc	Other-Appendix B Follow-Up questionn
Advance Letter Baseline Combined_REV Final.doc Advance Letter Baseline Combined	IC Document
Appendix K Participant Consent Language 2-8-2011.docx Consent Telephone Script (I/H)	IC Document
Advance Letter Baseline Combined_REV(SPANISH) Final.docx Advance Letter Baseline Combined_REV(SPANISH) Final.docx	IC Document
Advance Letter_FollowUp_Control_Eng_v1 Final.docx Advance Letter_FollowUp_Control_Eng	IC Document
Advance Letter_FollowUp_Control_Spanish_v3 Final.docx Advance Letter_FollowUp_Control_Spanish	IC Document
Advance Letter_FollowUp_Treatment_Eng_v1 Final.docx Advance Letter_FollowUp_Treatment_Eng	IC Document
Advance Letter_FollowUp_Treatment_Spanish_v3 Final.docx Advance Letter_FollowUp_Treatment_Spanish	IC Document

IC Title:

SEBTC - Households

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	Instrument File	Available Electronically?	Electronic Capability
Other-Baseline Questionnaire - English & Spanish	Appendix A English baseline instrument 3 15 Final.doc	No	Paper Only
Other-Appendix A :Spanish baseline instrument	Appendix A Spanish baseline instrument 3 15 11 final.doc	No	Paper Only
Other-Appendix B: English Follow-Up instrument	Appendix B English Follow-Up instrument 3 16 11 Final.doc	No	Paper Only
Other-Appendix B Follow-Up questionnaire SPANISH	Appendix B Follow-Up questionnaire SPANISH (3-16-11) Final.doc	No	Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,667

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	21,334	21,334
Annual IC Time Burden (Hours)	15,167	15,167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advance Letter Baseline Combined	Advance Letter Baseline Combined_REV Final.doc	03/17/2011
Consent Telephone Script (I/H)	Appendix K Participant Consent Language 2-8-2011.docx	02/08/2011
Advance Letter Baseline Combined_REV(SPANISH) Final.docx	Advance Letter Baseline Combined_REV(SPANISH) Final.docx	03/17/2011
Advance Letter_FollowUp_Control_Eng	Advance Letter_FollowUp_Control_Eng_v1 Final.docx	03/17/2011
Advance Letter_FollowUp_Control_Spanish	Advance Letter_FollowUp_Control_Spanish_v3 Final.docx	03/17/2011
Advance Letter_FollowUp_Treatment_Eng	Advance Letter_FollowUp_Treatment_Eng_v1 Final.docx	03/17/2011
Advance Letter_FollowUp_Treatment_Spanish	Advance Letter_FollowUp_Treatment_Spanish_v3 Final.docx	03/17/2011

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