Information Collection

Caregiver background questionnaire

IC 197849 under ICR 201111-0970-007 · OMB 0970-0392.

Documents and Forms

Document Name Document Type
Q-CCIIT Caregiver (10-25-11 dab) sm.docx Other-Caregiver Questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Caregiver background questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-Caregiver Questionnaire			Q-CCIIT Caregiver (10-25-11 dab) sm.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 460	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	460	-60	520
Annual IC Time Burden (Hours)	152	22	130
Annual IC Cost Burden (Dollars)	0	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.