Information Collection

Baseline Interview

IC 198825 under ICR 201406-0920-004 · OMB 0920-0895.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Baseline Interview Baseline Interview	Form and Instruction
3 Baseline Interview Att 5a_Baseline Survey.pdf	Form and Instruction

IC Title:

Baseline Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	3				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 400

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-400	400
Annual IC Time Burden (Hours)	-133	133
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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