Information Collection

Home Care Worker Pre Survey (English, Spanish, and Chinese)

IC 195731 under ICR 201012-0920-006 · OMB 0920-0880.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C1- Home care worker pre survey OMBcomments.docx	Other-WORD
Att I- Consent Documents (3).docx Att I- Consent Documents (3)	IC Document

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			Att C1- Home care worker pre survey OMBcomments.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 320

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 New Statute
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att I- Consent Documents (3)	Att I- Consent Documents (3).docx	03/08/2011

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