Information Collection

Baseline

IC 195854 under ICR 201403-0930-005 · OMB 0930-0320.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0320 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Client Baseline In Baseline	Form and Instruction
Client Baseline In Client Baseline Interview Att 01_Client Baseline Interview.doc	Form and Instruction
Att 04_SAMHSA Response to OMB_3.3.2011.docx SAMHSA Response to OMB	IC Document
Att 05_Client Interview Script.doc Client Interview Script	IC Document
Att 06_Client Interview Consent Form.doc Client Interview Consent Form	IC Document

IC Title:

Baseline

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Client Baseline Interview	Client Baseline Interview	Att 01_Client Baseline Interview.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,885

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,885	5,885
Annual IC Time Burden (Hours)	1,942	1,942
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SAMHSA Response to OMB	Att 04_SAMHSA Response to OMB_3.3.2011.docx	03/14/2014
Client Interview Script	Att 05_Client Interview Script.doc	03/14/2014
Client Interview Consent Form	Att 06_Client Interview Consent Form.doc	03/14/2014

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