Information Collection

Baseline Survey

IC 206720 under ICR 201304-0970-006 · OMB 0970-0439.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0439 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Baseline Survey	Form and Instruction
1 Baseline Survey IC 7 Baseline survey_final.docx	Form and Instruction

IC Title:

Baseline Survey

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	1	Baseline Survey	IC 7 Baseline survey_final.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

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
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,333	2,333
Annual IC Cost Burden (Dollars)	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.