Information Collection

Resident Baseline Survey -Core - LA County

IC 204426 under ICR 201210-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Resident Baseline Survey -Core - LA County	Form
Resident Baseline Survey - LA County - English Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc	Form
Resident Baseline Survey - LA County - Spanish Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc	Form
Att 8A-1(e)_MUH Resident Adult Consent.docx Adult Consent - English	IC Document
Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx Adult Consent - Spanish	IC Document
Att 8A-2(e)_LA HIPPA Form.docx LA HIPPA - English	IC Document
Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx LA HIPPA - Spanish	IC Document
Att 8A-3(e)_LA Resident Consent for Child Questions.docx LA Child Consent - English	IC Document
Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx LA Child Consent - Spanish	IC Document
Att 8A-4(e)_Resident Recruitment Materials.docx Recruitment Materials - English	IC Document
Att 8A-4(s)_Resident Recruitment Materials_8 30 2012.docx Recruitment Materials - Spanish	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
Form	none	Resident Baseline Survey - LA County - English	Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only
Form	none	Resident Baseline Survey - LA County - Spanish	Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	375	375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Adult Consent - English	Att 8A-1(e)_MUH Resident Adult Consent.docx	09/24/2012
Adult Consent - Spanish	Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx	09/24/2012
LA HIPPA - English	Att 8A-2(e)_LA HIPPA Form.docx	09/24/2012
LA HIPPA - Spanish	Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx	09/24/2012
LA Child Consent - English	Att 8A-3(e)_LA Resident Consent for Child Questions.docx	09/27/2012
LA Child Consent - Spanish	Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx	09/27/2012
Recruitment Materials - English	Att 8A-4(e)_Resident Recruitment Materials.docx	09/27/2012
Recruitment Materials - Spanish	Att 8A-4(s)_Resident Recruitment Materials_8 30 2012.docx	09/27/2012

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