Information Collection

Survey Instrument

IC 9803 under ICR 201205-0970-004 · OMB 0970-0033.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0033 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HHSP23320110005YC-Fully executed contract.pdf	Other-Contract
1 Annual Survey Questionnaire for OMB - English FINAL 3-14-12.pdf	Form and Instruction

IC Title:

Survey Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 4 CFR 45

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-Contract			HHSP23320110005YC-Fully executed contract.pdf		No	No	Fillable Printable
Form and Instruction	1	Annual Survey	Questionnaire for OMB - English FINAL 3-14-12.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,500	500	2,000
Annual IC Time Burden (Hours)	1,567	314	1,253
Annual IC Cost Burden (Dollars)	0	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.