Information Collection

Consumer Response Intake Form (Paper/Telephone)

IC 198358 under ICR 201302-3170-003 · OMB 3170-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3170-0011 can be found here:

Documents and Forms

Document Name Document Type
Phone Script Intake 3170-0011 DRAFT 2-24-2012.docx Other-Phone Script
TDF 104.3 Consumer Response Intake Form Paper Intake Form Mock Up Revised Privacy Statement OMB 6-11-2012.pdf Form
Paper_Version_Intake_Form_Mock_Up_OMB_No_3170-0011_REVISED_2_14_2012_NOT_IN_USE.pdf Prior version of the Intake Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Consumer Response Intake Form (Paper/Telephone)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Other-Phone Script			Phone Script Intake 3170-0011 DRAFT 2-24-2012.docx		Yes	No	Printable Only
Form	TDF 104.3	Consumer Response Intake Form	Paper Intake Form Mock Up Revised Privacy Statement OMB 6-11-2012.pdf		Yes	No	Printable Only

Line of Business: Economic Development

Subfunction: Industry Sector Income Stabilization

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	750,000	750,000
Annual IC Time Burden (Hours)	125,000	125,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Prior version of the Intake Form	Paper_Version_Intake_Form_Mock_Up_OMB_No_3170-0011_REVISED_2_14_2012_NOT_IN_USE.pdf	06/13/2012

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