Information Collection

Clients

IC 219456 under ICR 201601-0930-001 · OMB 0930-0355.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Client Focus Group Clients	Form and Instruction
Client Focus Group Client Focus Group 7-VITEL Client Focus Group v7.docx	Form and Instruction
BASELINE Client Le BASELINE Client Level Survey 10-VITEL BASELINE Client Level Survey v8.docx	Form and Instruction
DISCHARGE Client L DISCHARGE Client Level Survey 11-VITEL DISCHARGE Client Level Survey v6.docx	Form and Instruction
SIX MONTH FOLLOW-U SIX MONTH FOLLOW-UP Client Level Survey 12-VITEL SIX MONTH FOLLOW-UP Client Level Survey v6.docx	Form and Instruction
8-VITEL Client Consent Form v4.docx Client Consent Form	IC Document
13-VITEL Client Interaction Form v10.docx Client Interaction Form	IC Document
16-VITEL Client Data Sheet v4.docx Client Data Sheet	IC Document
14-Proposed Sampling v2.docx Proposed Sampling	IC Document

IC Title:

Clients

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Client Focus Group	Client Focus Group	7-VITEL Client Focus Group v7.docx	Yes	Yes	Fillable Fileable
Form and Instruction	BASELINE Client Level Survey	BASELINE Client Level Survey	10-VITEL BASELINE Client Level Survey v8.docx	Yes	Yes	Fillable Fileable
Form and Instruction	DISCHARGE Client Level Survey	DISCHARGE Client Level Survey	11-VITEL DISCHARGE Client Level Survey v6.docx	Yes	Yes	Fillable Fileable
Form and Instruction	SIX MONTH FOLLOW-UP Client Level Survey	SIX MONTH FOLLOW-UP Client Level Survey	12-VITEL SIX MONTH FOLLOW-UP Client Level Survey v6.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	1,890	1,890
Annual IC Time Burden (Hours)	846	846
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Client Consent Form	8-VITEL Client Consent Form v4.docx	01/04/2016
Client Interaction Form	13-VITEL Client Interaction Form v10.docx	01/04/2016
Client Data Sheet	16-VITEL Client Data Sheet v4.docx	01/04/2016
Proposed Sampling	14-Proposed Sampling v2.docx	01/04/2016

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