Baseline Interview

Community-based Organization (CBO) Monitoring and Evaluation Project of RESPECT (CMEP-RESPECT)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0895 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Baseline Interview Form and Instruction
3 Baseline Interview Att 5a_Baseline Survey.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Baseline Interview	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 and Instruction	3	Baseline Interview	Att 5a_Baseline Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 400

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	133	133
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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