Information Collection

Final In person interview

IC 207592 under ICR 201306-0990-003 · OMB 0990-0308.

Documents and Forms

IC Title:

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
Other-screen			0990-0308 Appendix B.doc		No	No	Paper Only
Other-interview			0990-0308 Appendix C.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 167

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	167	167
Annual IC Time Burden (Hours)	209	209
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-0308 Appendix A	0990-0308 Appendix A.doc	06/27/2013

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