Information Collection

FSS Evaluation

IC 205698 under ICR 201302-2528-001 · OMB 2528-0296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0296 can be found here:

Documents and Forms

Document Name Document Type
FSS Evaluation Form
Informed Consent Form MDRC_ICF for OMB revised 7-18-2013.doc Form
Baseline Information Form MDRC_BIF OMB final 7-18-2013.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FSS Evaluation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Informed Consent Form	MDRC_ICF for OMB revised 7-18-2013.doc		No		Paper Only
Form	N/A	Baseline Information Form	MDRC_BIF OMB final 7-18-2013.doc		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	9,378	9,378
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.