Information Collection

Participant Pretest (Adult intervention participants)

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Pretest (Adult intervention participants)	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	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 %

	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

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.