180-day Follow-up Interview

Community-based Organization (CBO) Monitoring and Evaluation Project of RESPECT (CMEP-RESPECT)

Documents and Forms

Document Name Document Type
180-day Follow-up Interview Form
180 day follow-up survey att3b_180-Day Follow-up Survey.docx Form
180 day follow up survey screenshots CMEP-RESPECT QDS Screen Shots 180-day Follow-up.pdf Form

Information Collection (IC) Details

IC Title:	180-day Follow-up Interview	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	none	180 day follow-up survey	att3b_180-Day Follow-up Survey.docx		Yes	Yes	Fillable Fileable
Form	none	180 day follow up survey screenshots	CMEP-RESPECT QDS Screen Shots 180-day Follow-up.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	96	96
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.