Information Collection

Client Initial Script Refusal

IC 207800 under ICR 201606-0930-003 · OMB 0930-0274.

Documents and Forms

Document Name Document Type
Form Client Initial Scr Client Initial Script Refusal Form and Instruction
Client Initial Scr Client Initial Script Attachment B. Client Initial Script 031516.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Client Initial Script Refusal	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 and Instruction	Client Initial Script	Client Initial Script	Attachment B. Client Initial Script 031516.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	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	53	-68	121
Annual IC Time Burden (Hours)	1	-1	2
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.