Information Collection

Baseline Interview Guide

IC 205168 under ICR 201608-0930-001 · OMB 0930-0336.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Baseline Interview Baseline Interview Guide	Form and Instruction
Baseline Interview Baseline Interview Guide MAI-COC Baseline Interview Guide_042816.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	Baseline Interview Guide	Baseline Interview Guide	MAI-COC Baseline Interview Guide_042816.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 306

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	306	306
Annual IC Time Burden (Hours)	612	612
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.