FSS Evaluation

Family Self-Sufficiency Program Evaluation

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.