Information Collection

Baseline Survey of impact study participants

IC 223265 under ICR 201606-0990-004 · OMB 0990-0452.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0452 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 1_BaselineSurvey_revised_8.19.16.docx	Instruction

IC Title:

Baseline Survey of impact study participants

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
Instruction			Instrument 1_BaselineSurvey_revised_8.19.16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 865

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	865	865
Annual IC Time Burden (Hours)	433	433
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.