Information Collection

Participant Pretest (Adult intervention participants)

IC 210066 under ICR 201401-0925-005 · OMB 0925-0694.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Participant Pretest (Adult intervention participants)	Form and Instruction
1 Participant Pretest 3A - NDEP DHS Particpant Pretest_121913_OMB30.pdf	Form and Instruction
3A - NDEP DHS Participant Pretest_110613_OMB30.docx 3A - NDEP DHS Participant Pretest_110613_OMB30	IC Document

IC Title:

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	1	Participant Pretest	3A - NDEP DHS Particpant Pretest_121913_OMB30.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

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	200	200
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
3A - NDEP DHS Participant Pretest_110613_OMB30	3A - NDEP DHS Participant Pretest_110613_OMB30.docx	01/13/2014

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