Information Collection

Baseline Questionnaire

IC 199770 under ICR 201204-0920-004 · OMB 0920-0913.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0913 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 3d Baseline Questionnaire MLMS Change.doc	Other-WORD
Attachment 4a MyLife, MyStyle Informed Consent Form 6.15.11.docx Attachment 4a MyLife, MyStyle Informed Consent Form 6	IC Document

IC Title:

Baseline Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

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-WORD			Attachment 3d Baseline Questionnaire MLMS Change.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 528

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	528	528
Annual IC Time Burden (Hours)	528	528
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 4a MyLife, MyStyle Informed Consent Form 6	Attachment 4a MyLife, MyStyle Informed Consent Form 6.15.11.docx	10/14/2011

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