Information Collection

Baseline Survey

IC 212078 under ICR 201505-0990-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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
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 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
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

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.