Information Collection

Food and Nutrition Service (FNS) Form Cognitive Testing

IC 222835 under ICR 201607-0607-003 · OMB 0607-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FNS_PROTOCOL_PROTOYPE_APPLICANT_V5.docx	Instruction
FNS_PROTOCOL_ADMIN_V2.docx	Instruction
2016-2017 Prototyp 2016-2017 Prototype Household Application for Free and R FNS 2016-2017 Household Application Form.pdf	Form
FNS OMB Memo v2.docx Memo	IC Document
FNS FAQ.pdf FAQs	IC Document
FNS Instructions.pdf Instructions	IC Document
FNS Consent Form.docx Consent Form	IC Document
FNS_APPLICANT_SCREENER_ADDL_QUESTIONS.docx Screener	IC Document

IC Title:

Food and Nutrition Service (FNS) Form Cognitive Testing

Agency IC Tracking Number:

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
Instruction			FNS_PROTOCOL_PROTOYPE_APPLICANT_V5.docx	Yes	Yes	Paper Only
Instruction			FNS_PROTOCOL_ADMIN_V2.docx	Yes	Yes	Paper Only
Form	2016-2017 Prototype Household Application	2016-2017 Prototype Household Application for Free and Reduced Price School Meals	FNS 2016-2017 Household Application Form.pdf	Yes	Yes	Paper Only

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 180

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	293	293
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Memo	FNS OMB Memo v2.docx	08/03/2016
FAQs	FNS FAQ.pdf	08/03/2016
Instructions	FNS Instructions.pdf	08/03/2016
Consent Form	FNS Consent Form.docx	08/03/2016
Screener	FNS_APPLICANT_SCREENER_ADDL_QUESTIONS.docx	08/03/2016

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