Information Collection

Record Review Worksheet

IC 181816 under ICR 201506-0970-011 · OMB 0970-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0323 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Record Review Worksheet	Form and Instruction
1 Data Collection Instructions 2015 Data Collection Instructions 2015.docx	Form and Instruction

IC Title:

Record Review Worksheet

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 98

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	1	Data Collection Instructions 2015	Data Collection Instructions 2015.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,692	4,692
Annual IC Time Burden (Hours)	29,700	29,700
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.