Information Collection

Student Outcome Survey Baseline

IC 199966 under ICR 201110-0920-012 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Student Outcome Survey Baseline	Form and Instruction
1 Student Outcome Survey - Baseline Attachment D - Student+Outcome+Survey+-+Baseline.docx	Form and Instruction
Attachment TT - Student+Assent+Form.docx Attachment TT - Student+Assent+Form	IC Document
Attachment UU - Parent+Consent+for+Student+Form.docx Attachment UU - Parent+Consent+for+Student+Form	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 and Instruction	1	Student Outcome Survey - Baseline	Attachment D - Student+Outcome+Survey+-+Baseline.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,600	9,600
Annual IC Time Burden (Hours)	14,400	14,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment TT - Student+Assent+Form	Attachment TT - Student+Assent+Form.docx	10/21/2011
Attachment UU - Parent+Consent+for+Student+Form	Attachment UU - Parent+Consent+for+Student+Form.docx	10/21/2011

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