Information Collection

One-toOne Evaluation Study Questionnaire

IC 217718 under ICR 201507-0925-009 · OMB 0925-0729.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0729 can be found here:

Documents and Forms

Document Name Document Type
Form 10 One-toOne Evaluation Study Questionnaire Form and Instruction
10 Attachment H One-to One Evaluation Study Questionnaire Attachment H_One-to-One Evaluation Study Questionnaire.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	One-toOne Evaluation Study Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	10	Attachment H One-to One Evaluation Study Questionnaire	Attachment H_One-to-One Evaluation Study Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	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.