Information Collection

Baseline Survey

IC 212078 under ICR 201406-0990-001 · OMB 0990-0424.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0424 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx	Other-Plan
0990_Attachment G_Baseline Pretest Memo.pdf Attachment G Baseline Pretest Memo	IC Document
0990_Attachment I_Persons Consulted.docx Attachment I Person Consulted on Instrument	IC Document
0990-Attachment K_Confidentiality Pledge.pdf Attachment K Confidential Pledge	IC Document
0990-Attachment M_Overview for Grantees.pdf Attachment M Overview For Grantees	IC Document
0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx Consent Letters and Forms, Youth Assent Form, and Contact Information Sheet	IC Document
0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx Consent Letters and Forms, Youth Assent Form, and contact Information sheet	IC Document
0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx Analysis Plan for PAF Impact Study	IC Document
0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx Consent letters, and Forms, Youth Assent Form, and Contact information Sheet	IC Document
0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx Analysis Plan for PAF Impact Study	IC Document
0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx consent letters and forms youth assent form	IC Document
0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx Analysis plan for PAF zimpact study	IC Document

IC Title:

Baseline Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-Plan			0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	950	950
Annual IC Time Burden (Hours)	475	475
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment G Baseline Pretest Memo	0990_Attachment G_Baseline Pretest Memo.pdf	06/25/2014
Attachment I Person Consulted on Instrument	0990_Attachment I_Persons Consulted.docx	06/25/2014
Attachment K Confidential Pledge	0990-Attachment K_Confidentiality Pledge.pdf	06/25/2014
Attachment M Overview For Grantees	0990-Attachment M_Overview for Grantees.pdf	06/25/2014
Consent Letters and Forms, Youth Assent Form, and Contact Information Sheet	0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx	08/29/2014
Consent Letters and Forms, Youth Assent Form, and contact Information sheet	0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx	08/29/2014
Analysis Plan for PAF Impact Study	0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx	08/29/2014
Consent letters, and Forms, Youth Assent Form, and Contact information Sheet	0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx	08/29/2014
Analysis Plan for PAF Impact Study	0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx	08/29/2014
consent letters and forms youth assent form	0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx	08/29/2014
Analysis plan for PAF zimpact study	0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx	08/29/2014

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