Information Collection

Baseline Assessment

IC 202457 under ICR 201205-0920-010 · OMB 0920-0945.

Documents and Forms

Document Name Document Type
Form Attachment 6 Baseline Assessment Form
Attachment 6 Baseline Assessment Baseline Assessment_OMB Comments.7.4.12 revised_clean.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form	Attachment 6	Baseline Assessment	Baseline Assessment_OMB Comments.7.4.12 revised_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 146	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	146	146
Annual IC Time Burden (Hours)	146	146
Annual IC Cost Burden (Dollars)	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.