Information Collection

Adult Program Pilot

IC 200242 under ICR 201301-1505-001 · OMB 1505-0242.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
adult pilot_ post card 01.05.11.docx	Other-Post Card
adult pilot_Baseline Survey_01.16.11 .docx	Other-Survey
adult pilot_BP data release form.doc	Other-Release
adult pilot_consent form_12.15.12.doc	Other-Consent
adult pilot_consent script 01.15.12.docx	Other-Consent Script
adult pilot_cover letters_POP 01.15.12 .docx	Other-Cover Letter
adult pilot_FUsurvey_01.15.12 .docx	Other-Survey
adult pilot_onsite survey guidance 01.15.12.docx	Other-Survey Guidance
Adult Survey Reminders_MAY2012.pdf	Other-Post Card REV
Adult Survey Cover Letters_MAY2012.pdf	Other-Cover Letter REV
Adult Follow-up Survey_MAY2012.pdf	Other-Survey REV

IC Title:

Adult Program Pilot

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Post Card	adult pilot_ post card 01.05.11.docx	Yes	No	Printable Only
Other-Survey	adult pilot_Baseline Survey_01.16.11 .docx	Yes	No	Printable Only
Other-Release	adult pilot_BP data release form.doc	Yes	No	Printable Only
Other-Consent	adult pilot_consent form_12.15.12.doc	Yes	No	Printable Only
Other-Consent Script	adult pilot_consent script 01.15.12.docx	Yes	No	Printable Only
Other-Cover Letter	adult pilot_cover letters_POP 01.15.12 .docx	Yes	No	Printable Only
Other-Survey	adult pilot_FUsurvey_01.15.12 .docx	Yes	No	Printable Only
Other-Survey Guidance	adult pilot_onsite survey guidance 01.15.12.docx	Yes	No	Printable Only
Other-Post Card REV	Adult Survey Reminders_MAY2012.pdf	Yes	No	Printable Only
Other-Cover Letter REV	Adult Survey Cover Letters_MAY2012.pdf	Yes	No	Printable Only
Other-Survey REV	Adult Follow-up Survey_MAY2012.pdf	Yes	No	Printable Only

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,031

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,031	31	1,000
Annual IC Time Burden (Hours)	452	-548	1,000
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.