Information Collection

Baseline Interview

IC 217703 under ICR 201511-0920-003 · OMB 0920-1005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment D1 Screener and baseline interviewer guide_1005 OlderAdult ICRO Correct.docx	Other-Interview Script

IC Title:

Baseline Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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-Interview Script			Attachment D1 Screener and baseline interviewer guide_1005 OlderAdult ICRO Correct.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42484

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	167	167
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.