Information Collection

Neighborhood Interview

IC 212624 under ICR 201605-0920-006 · OMB 0920-1038.

Documents and Forms

Document Name Document Type
Neighborhood Interview Form
Neighborhood Survey Att 6_Nhood Int Survey.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Neighborhood Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Neighborhood Survey	Att 6_Nhood Int Survey.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	40	160
Annual IC Time Burden (Hours)	67	14	53
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.