Information Collection

Evaluator Interview

IC 208309 under ICR 201308-0930-002 · OMB 0930-0339.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0339 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Discussion Guide_C Evaluator Interview	Form and Instruction
Discussion Guide_C Discussion Guide_Cost Questionnaire Attachment 02_SV Discussion Guide_Cost Questionnaire.docx	Form and Instruction
Attachment 06 and 07_Staff and Client SiteVisit Consent.docx Staff and Client SiteVisit Consent.	IC Document

IC Title:

Evaluator Interview

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	Discussion Guide_Cost Questionnaire	Discussion Guide_Cost Questionnaire	Attachment 02_SV Discussion Guide_Cost Questionnaire.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Staff and Client SiteVisit Consent.	Attachment 06 and 07_Staff and Client SiteVisit Consent.docx	08/19/2013

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