Information Collection

Outcome Baseline in Person

IC 218388 under ICR 201509-0910-011 · OMB 0910-0808.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0808 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment6_WebSurveyInformedConsent.docx	Other-Web Survey Informed Consent
Attachment1_BaselineWebSurvey.docx	Other-Baseline Web Survey

IC Title:

Outcome Baseline in Person

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
Other-Web Survey Informed Consent			Attachment6_WebSurveyInformedConsent.docx		Yes	Yes	Fillable Fileable
Other-Baseline Web Survey			Attachment1_BaselineWebSurvey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 788

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	788	788
Annual IC Time Burden (Hours)	394	394
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.