Information Collection

Interview Form

IC 198961 under ICR 201108-0930-001 · OMB 0930-0331.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Interview Form Interview Form	Form and Instruction
Interview Form Interview form Attachment 1_State Video Contacts Feedback Form_102611.doc	Form and Instruction

IC Title:

Interview Form

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 and Instruction	Interview Form	Interview form	Attachment 1_State Video Contacts Feedback Form_102611.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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	15	15
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.