Information Collection

Interview

IC 202477 under ICR 201205-0930-002 · OMB 0930-0334.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0334 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment B-CAI Interview	Form and Instruction
Attachment B-CAI Attachment B-CAI Attachment B-CAI.pdf	Form and Instruction
Attachments A,C,D,E.pdf Attachments A,C,D,E	IC Document
Attachments F,G,R,S.pdf Attachments F,G,R,S	IC Document
Attachment H.pdf Attachment H	IC Document
Attachment I,J.pdf Attachment I,J	IC Document
Attachment K.pdf Attachment K	IC Document
Attachments L,M,N.pdf Attachments L,M,N	IC Document
Attachment O,P-Letters.pdf Attachment O,P-Letters	IC Document
Attachment Q.pdf Attachment Q-Refusal Letters	IC Document

IC Title:

Interview

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 and Instruction	Attachment B-CAI	Attachment B-CAI	Attachment B-CAI.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments A,C,D,E	Attachments A,C,D,E.pdf	05/17/2012
Attachments F,G,R,S	Attachments F,G,R,S.pdf	05/17/2012
Attachment H	Attachment H.pdf	05/17/2012
Attachment I,J	Attachment I,J.pdf	05/17/2012
Attachment K	Attachment K.pdf	05/17/2012
Attachments L,M,N	Attachments L,M,N.pdf	05/17/2012
Attachment O,P-Letters	Attachment O,P-Letters.pdf	05/17/2012
Attachment Q-Refusal Letters	Attachment Q.pdf	05/17/2012

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