Information Collection

Other Key Staff Site Visit Interview

IC 218982 under ICR 201511-0925-003 · OMB 0925-0734.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 12 Attachment 7 Key Staff Interview Protocol Other Key Staff Site Visit Interview	Form and Instruction
Form 13 Attachment 9 Evaluator Interview Protocol Other Key Staff Site Visit Interview	Form and Instruction
12 Attachment 7 Key Staff Interview Protocol Attachment 7. Key Staff Interview Protocol.docx	Form and Instruction
13 Attachment 9 Evaluator Interview Protocol Attachment 8. Evaluator Interview Protocol.docx	Form and Instruction

IC Title:

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
Form and Instruction	12				No		Fillable Fileable
Form and Instruction	13				No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	135	135
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.

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