Information Collection

Instrument 5: Baseline survey - HM Study Participants

IC 206001 under ICR 201303-0970-001 · OMB 0970-0403.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0403 can be found here:

Documents and Forms

Document Name Document Type
PACT Instrument (5) - Baseline Survey for Participants in Healthy Marria.docx Other-Survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Instrument 5: Baseline survey - HM Study Participants	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
Other-Survey			PACT Instrument (5) - Baseline Survey for Participants in Healthy Marria.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	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	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
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.