Information Collection

Interview with Community Representatives

IC 198624 under ICR 201107-0920-005 · OMB 0920-0897.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interview with Community Representatives	Form
Community Representative Interview Guide C-1 Comm Rep Interview Guide.doc	Form
C-3 Comm Rep Consent Form.doc Att C3 - Consent for Community Reps	IC Document
C-2 Comm Rep Information Sheet.doc Att C2 - Info Sheet for Community Reps	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
Form	none	Community Representative Interview Guide	C-1 Comm Rep Interview Guide.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att C3 - Consent for Community Reps	C-3 Comm Rep Consent Form.doc	07/20/2011
Att C2 - Info Sheet for Community Reps	C-2 Comm Rep Information Sheet.doc	07/20/2011

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