Evaluation Questionnaire

WHAM: Women Health and Mindfulness Program

Documents and Forms

Document Name Document Type
19144 _ID (WHAM) Women's Health and Mindfulness Program - Mindfulness Study Baseline Evaluation Questionnaire(1).docx Other-survey
RTI_LMHS_OMB_Attachments_Baseline Questionnaire_august2013.docx Other-Questionnaire

Information Collection (IC) Details

IC Title:	Evaluation Questionnaire	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-Questionnaire			RTI_LMHS_OMB_Attachments_Baseline Questionnaire_august2013.docx		No		Printable Only
Other-survey			19144 _ID (WHAM) Women's Health and Mindfulness Program - Mindfulness Study Baseline Evaluation Questionnaire(1).docx		No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	80	80
Annual IC Time Burden (Hours)	60	60
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.