Information Collection

Baseline

IC 204567 under ICR 201210-0930-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Baseline Client Baseline	Form and Instruction
Baseline Client Baseline Client A.1 Baseline Client Interview.pdf	Form and Instruction
Attachment D. Sample introductory and reminder emails_7 19 12.pdf Sample introductory and reminder emails	IC Document

IC Title:

Baseline

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	Baseline Client	Baseline Client	A.1 Baseline Client Interview.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 662

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	662	662
Annual IC Time Burden (Hours)	166	166
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample introductory and reminder emails	Attachment D. Sample introductory and reminder emails_7 19 12.pdf	09/27/2012

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