Information Collection

Adults Programs Usage Log

IC 209243 under ICR 201311-0925-001 · OMB 0925-0685.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0685 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Adults Programs Usage Log	Form
6 Adults Usage Log Attachment 16 Data Collection Instrument_Adults Program Usage Log.docx	Form

IC Title:

Adults Programs Usage Log

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	6	Adults Usage Log	Attachment 16 Data Collection Instrument_Adults Program Usage Log.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SORN 09-25-0200

FR Citation: 67 FR 60741

Number of Respondents: 200

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	400	400
Annual IC Time Burden (Hours)	67	67
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.