Information Collection

CAPP Caregiver Questionnaire

IC 218900 under ICR 201511-0970-001 · OMB 0970-0408.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A4a Caregiver Informed Consent and Questionnaire Paper.PDF	Other-Questionnaire
Attachment A6a-9 Caregiver IC-Questionnaire Telephone-10_15-FINAL.DOCX	Other-Questionnaire
Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish 10-15.pdf Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish	IC Document
Attachment A6b_ Caregiver IC-Questionnaire Telephone Spanish-10_15-FINA....docx Attachment A6b Caregiver IC-Questionnaire Telephone Spanish	IC Document

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
Other-Questionnaire			Attachment A4a Caregiver Informed Consent and Questionnaire Paper.PDF		No		Paper Only
Other-Questionnaire			Attachment A6a-9 Caregiver IC-Questionnaire Telephone-10_15-FINAL.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 587

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	587	587
Annual IC Time Burden (Hours)	352	352
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish	Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish 10-15.pdf	11/17/2015
Attachment A6b Caregiver IC-Questionnaire Telephone Spanish	Attachment A6b_ Caregiver IC-Questionnaire Telephone Spanish-10_15-FINA....docx	11/17/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.