Information Collection

Baseline Assessment Questionnaire

IC 201267 under ICR 201202-0920-004 · OMB 0920-0942.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0942 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 4 Baseline Assessment questionnaire[1].pdf	Other-Attachment 4 Baseline Assessme

IC Title:

Baseline Assessment Questionnaire

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
Other-Attachment 4 Baseline Assessment questionnaire			Attachment 4 Baseline Assessment questionnaire[1].pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	525	525
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.