Information Collection

Participant Follow-up Interview

IC 210069 under ICR 201401-0925-005 · OMB 0925-0694.

Documents and Forms

Document Name Document Type
Form 4 Participant Follow-up Interview Form and Instruction
4 Participant Follow-Up Interview 3D - NDEP DHS Participant Follow-Up Interview Guide_110613_OMB30.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Follow-up 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	4	Participant Follow-Up Interview	3D - NDEP DHS Participant Follow-Up Interview Guide_110613_OMB30.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	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	10	10
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.