Information Collection

Telephone Interview Discussion Guide

IC 204007 under ICR 201209-0990-002 · OMB 0990-0404.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B2_Fact Sheet Template.docx	Other-Fact Sheet
Attachment B1_Discussion Guide.docx	Other-Discussion Guide
Attachment D1_State Letter.docx State Letter	IC Document
Attachment E_Design Report.pdf Design Report	IC Document
Attachment D2_Consent Form_Nov 12 2012.docx Attachment D2_Consent Form_Nov 12 2012	IC Document

IC Title:

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
Other-Fact Sheet			Attachment B2_Fact Sheet Template.docx		No	No	Paper Only
Other-Discussion Guide			Attachment B1_Discussion Guide.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 77

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	77	77
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
State Letter	Attachment D1_State Letter.docx	08/08/2012
Design Report	Attachment E_Design Report.pdf	08/08/2012
Attachment D2_Consent Form_Nov 12 2012	Attachment D2_Consent Form_Nov 12 2012.docx	11/15/2012

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