Information Collection

ALA Baseline Survey

IC 215416 under ICR 201502-0920-019 · OMB 0920-1067.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1067 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ALA Baseline Survey	Form and Instruction
ALA Baseline Survey Attachment D ALABaselineSurvey_CDC30Day_02 04 15.pdf	Form and Instruction

IC Title:

ALA 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
Form and Instruction	None	ALA Baseline Survey	Attachment D ALABaselineSurvey_CDC30Day_02 04 15.pdf	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	458	458
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.