Information Collection

Client Pre Survey (English, Spanish, and Chinese)

IC 195733 under ICR 201012-0920-006 · OMB 0920-0880.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C3- Client pre survey OMBcomments.docx	Other-WORD
Att I_Consent documents.doc Att I_Consent documents	IC Document
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					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)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att I_Consent documents		11/01/2010
Att I- Consent Documents (3)		03/08/2011

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].