Information Collection

Baseline Survey

IC 207815 under ICR 201307-0990-002 · OMB 0990-0412.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Baseline Survey (DIFO) Doing It For Ourselves REV. 8-22-13.DOCX	Other-survey
Baseline Survey (DIFO) SurveyMonkey Screenshots 8-26-2013.DOCX	Other-ScreenShot

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
Other-survey					No	No	Paper Only
Other-ScreenShot					No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 168

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	168	168
Annual IC Time Burden (Hours)	84	84
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.

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