Baseline Data Collection, Staff

Green Jobs and Health Care Impact Evaluation of ARRA-funded Grants

Documents and Forms

Document Name Document Type
GJHC Participant Consent Form 3-9-12 (Final).doc Other-participant consent form
Green Jobs Baseline Information Form (3-9-12 FINAL).doc Other-Baseline Information form
GJ-HC Informed Consent Script to OMB 3-9-12.doc Other-informed consent script

Information Collection (IC) Details

IC Title:	Baseline Data Collection, Staff	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-participant consent form	GJHC Participant Consent Form 3-9-12 (Final).doc	Yes	Yes	Paper Only
Other-Baseline Information form	Green Jobs Baseline Information Form (3-9-12 FINAL).doc	Yes	Yes	Fillable Fileable
Other-informed consent script	GJ-HC Informed Consent Script to OMB 3-9-12.doc	Yes	Yes	Paper Only

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	16	-5,984	6,000
Annual IC Time Burden (Hours)	768	-532	1,300
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.