Baseline

Cross-Site Evaluation for the Benefit of Homeless Individuals (GBHI)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.