Information Collection

Baseline Assessment

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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.