Baseline

Cross-Site Evaluation for the Benefit of Homeless Individuals (GBHI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0320 can be found here:

Documents and Forms

Document Name Document Type
Form Client Interview_B Baseline Form
Client Interview_B Client Interview_Baseline 2 Attachment 2_Client Interview_Baseline_3.3.11.doc Form
1 Attachment 1_SAMHSA Priority Goals.doc SAMHSA Priority Goals IC Document
5 Attachment 5_Client Interview Script.doc Client Interview Script IC Document
6 Attachment 6_Client Interview Consent Form.doc Client Interview Consent IC Document
8 Attachment 8_Privacy Pledge.doc Privacy Pledge IC Document
9 Attachment 9_ClientDataIRBApproval.pdf Client Data IRB Approval IC Document

Information Collection (IC) Details

IC Title:	Baseline	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Client Interview_Baseline	Client Interview_Baseline	2 Attachment 2_Client Interview_Baseline_3.3.11.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,885	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,885	5,885
Annual IC Time Burden (Hours)	1,942	1,942
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SAMHSA Priority Goals	1 Attachment 1_SAMHSA Priority Goals.doc	03/16/2011
Client Interview Script	5 Attachment 5_Client Interview Script.doc	03/16/2011
Client Interview Consent	6 Attachment 6_Client Interview Consent Form.doc	03/16/2011
Privacy Pledge	8 Attachment 8_Privacy Pledge.doc	03/16/2011
Client Data IRB Approval	9 Attachment 9_ClientDataIRBApproval.pdf	03/16/2011

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