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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.