Information Collection

FSS Evaluation

IC 205698 under ICR 201607-2528-002 · OMB 2528-0296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0296 can be found here:

Documents and Forms

Document Name Document Type
Draft mini-survey questionnaire 2014-02-04_Updated.docx Other-Draft mini-survey questionnair
XX-XXXX Informed Consent FSS EVALUATION OMB PACKET PART A - APPENDIX INFORMED CONSENT FORM.doc Form
XX-XXXX Baseline Information Form-Head of Household FSS_A_4a_BIF_Household.docx Form
Baseline Informati XX-XXXX FSS_A_4b_BIF_Adult.docx Form
XX-XXXX 36 Month Follow-up Survey FSS NATIONAL EVALUATION 36 month survey draft_CLEAN_7.2016.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FSS Evaluation	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	Available Electronically?	Electronic Capability
Other-Draft mini-survey questionnaire			Draft mini-survey questionnaire 2014-02-04_Updated.docx	No	Paper Only
Form	XX-XXXX	Informed Consent	FSS EVALUATION OMB PACKET PART A - APPENDIX INFORMED CONSENT FORM.doc	No	Paper Only
Form	XX-XXXX	Baseline Information Form-Head of Household	FSS_A_4a_BIF_Household.docx	No	Paper Only
Form	Baseline Information Form Adult	XX-XXXX	FSS_A_4b_BIF_Adult.docx	No	Paper Only
Form	XX-XXXX	36 Month Follow-up Survey	FSS NATIONAL EVALUATION 36 month survey draft_CLEAN_7.2016.docx	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,551	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,551	-2,407	4,958
Annual IC Time Burden (Hours)	1,913	-2,503	4,416
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.