Information Collection

One-toOne Evaluation Study Questionnaire

IC 217718 under ICR 201511-0925-006 · OMB 0925-0729.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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
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 %

table that charts list of burden
	Approved	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

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.