Information Collection

FSS Evaluation

IC 205698 under ICR 201501-2528-004 · OMB 2528-0296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0296 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FSS Evaluation	Form
Draft mini-survey questionnaire 2014-02-04_Updated.docx	Other-Draft mini-survey questionnair
Informed Consent Form MDRC_ICF for OMB revised 7-18-2013.doc	Form
Baseline Information Form MDRC_BIF OMB final 7-18-2013.doc	Form

IC Title:

FSS Evaluation

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	Available Electronically?	Electronic Capability
Form	N/A	Informed Consent Form	MDRC_ICF for OMB revised 7-18-2013.doc	No	Paper Only
Form	N/A	Baseline Information Form	MDRC_BIF OMB final 7-18-2013.doc	No	Paper Only
Other-Draft mini-survey questionnaire			Draft mini-survey questionnaire 2014-02-04_Updated.docx	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,803

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	Previously Approved
Annual Number of Responses for this IC	4,958	1,958	3,000
Annual IC Time Burden (Hours)	4,416	-4,962	9,378
Annual IC Cost Burden (Dollars)	0	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.