Information Collection

Community Health Worker Interview Protocol

IC 209801 under ICR 201403-0915-005 · OMB 0915-0383.

Documents and Forms

Document Name Document Type
Form 4 Community Health Worker Interview Protocol Form and Instruction
4 Community Health Worker Interview Protocol CommunityHealthWorker_OMBClearancePackage_092413.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Community Health Worker Interview Protocol	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	Community Health Worker Interview Protocol	CommunityHealthWorker_OMBClearancePackage_092413.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	Number of Respondents for Small Entity: 11

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	11	11
Annual IC Time Burden (Hours)	11	11
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.