Information Collection

Consumer Response Intake Form (Paper/Telephone)

IC 198358 under ICR 201202-3170-001 · OMB 3170-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3170-0011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TDF 104.3 Consumer Response Intake Form (Paper/Telephone)	Form
Phone Script Intake 3170-0011 DRAFT 2-24-2012.docx	Other-Phone Script
TDF 104.3 Consumer Response Intake Form Paper Version Intake Form Mock Up OMB No 3170-0011 REVISED 2 14 2012 NOT IN USE.pdf	Form

IC Title:

Consumer Response Intake Form (Paper/Telephone)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	TDF 104.3	Consumer Response Intake Form	Paper Version Intake Form Mock Up OMB No 3170-0011 REVISED 2 14 2012 NOT IN USE.pdf		No		Printable Only
Other-Phone Script			Phone Script Intake 3170-0011 DRAFT 2-24-2012.docx		Yes	No	Printable Only

Line of Business: Economic Development

Subfunction: Industry Sector Income Stabilization

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 750,000

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	Previously Approved
Annual Number of Responses for this IC	750,000	750,000
Annual IC Time Burden (Hours)	125,000	125,000
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.