Information Collection

Disability Employment Initiative Grantee Site Visits - State Employees

IC 197615 under ICR 201104-1230-001 · OMB 1230-0006.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DEI Eval Site Visit Question Matrix.xls	Other-Interview Guide
101812_ME DEI Supplemental Questionnaire REVISED 1-25-13 20130123).docx DEI Supplemental Questionnaire for Maine	IC Document
101812_WI DEI Supplemental Questionnaire-Berge REVISED 1-25-13 20130123.docx DEI Supplemental Questionnaire for Wisconsin	IC Document
DEI_Training_Site_Visit__Interview_Logistics__Protocol_01-26-13_JV_Final.doc Site Visit Protocol	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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-Interview Guide			DEI Eval Site Visit Question Matrix.xls		No		Paper Only

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title: System of Records Notice, DOL/ETA-15

FR Citation: 67 FR 16898

Number of Respondents: 16

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	368	368
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DEI Supplemental Questionnaire for Maine	101812_ME DEI Supplemental Questionnaire REVISED 1-25-13 20130123).docx	01/30/2013
DEI Supplemental Questionnaire for Wisconsin	101812_WI DEI Supplemental Questionnaire-Berge REVISED 1-25-13 20130123.docx	01/30/2013
Site Visit Protocol	DEI_Training_Site_Visit__Interview_Logistics__Protocol_01-26-13_JV_Final.doc	01/30/2013

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