Information Collection

Home Care Worker Interest Response Form

IC 195735 under ICR 201012-0920-006 · OMB 0920-0880.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att D2_Recruitment Response Form.doc	Other-WORD
Att D1_Recruitment Info.doc Att D1_Recruitment Info	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: 500

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	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D1_Recruitment Info		11/01/2010

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

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