Information Collection

Baseline Survey of impact study participants

IC 212078 under ICR 201604-0990-002 · OMB 0990-0424.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0424Attachment G_PAF Follow up Pretest Memorandum.docx	Other-baseline survey
0990_Attachment G_Baseline Pretest Memo.pdf Attachment G Baseline Pretest Memo	IC Document
0990_Attachment I_Persons Consulted.docx Attachment I Person Consulted on Instrument	IC Document
0990-Attachment K_Confidentiality Pledge.pdf Attachment K Confidential Pledge	IC Document
0990-Attachment M_Overview for Grantees.pdf Attachment M Overview For Grantees	IC Document
0990-Attachment J_PAF_Consent Letters and Forms and Youth Assent Form_08262014.docx Consent Letters and Forms, Youth Assent Form, and Contact Information Sheet	IC Document
0990-Attachment L_PAF Analysis Plan for Impact Study_revised.docx Analysis Plan for PAF Impact Study	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-baseline survey					Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 673

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	673	673
Annual IC Time Burden (Hours)	337	337
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment G Baseline Pretest Memo		06/25/2014
Attachment I Person Consulted on Instrument		06/25/2014
Attachment K Confidential Pledge		06/25/2014
Attachment M Overview For Grantees		06/25/2014
Consent Letters and Forms, Youth Assent Form, and Contact Information Sheet		08/29/2014
Analysis Plan for PAF Impact Study		08/29/2014

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

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