ConnectHome Baseline Survey

ConnectHome Baseline Survey Data Collection

Documents and Forms

Document Name Document Type
Formatted ConnectHome Baseline Survey Revised 8_4_16.docx Other-Baseline Survey English
Formatted ConnectHome Baseline Survey-Vietnamese Revised 8_4_16.docx Other-Baseline Survey Vietnamese
Formatted ConnectHome Baseline Survey-Spanish Revised 8_4_16.docx Other-Baseline Survey Spanish
Formatted ConnectHome baseline Survey-Amharic Revised 8_4_16.doc Other-Baseline Survey Amharic
Formatted ConnectHome Baseline Survey-Arabic Revised 8_4_16.docx Other-Baeline Survey Arabic
Formatted ConnectHome Baseline Survey-Hmong Revised 8_4_16.docx Other-Baseline Survey Hmong
Formatted ConnectHome Baseline Survey-S.Chinese Revised 8_4_16.docx Other-Baseline Survey Chinese
Formatted ConnectHome Baseline Survey-Russian Revised 8_4_16.docx Other-Baseline Survey Russian
Formatted ConnectHome Baseline Survey-Somali Revised 8_4_16.docx Other-Baseline Survey Somali

Information Collection (IC) Details

IC Title:	ConnectHome Baseline Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Baseline Survey English	Formatted ConnectHome Baseline Survey Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Vietnamese	Formatted ConnectHome Baseline Survey-Vietnamese Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Spanish	Formatted ConnectHome Baseline Survey-Spanish Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Amharic	Formatted ConnectHome baseline Survey-Amharic Revised 8_4_16.doc	No	Paper Only
Other-Baeline Survey Arabic	Formatted ConnectHome Baseline Survey-Arabic Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Hmong	Formatted ConnectHome Baseline Survey-Hmong Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Chinese	Formatted ConnectHome Baseline Survey-S.Chinese Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Russian	Formatted ConnectHome Baseline Survey-Russian Revised 8_4_16.docx	No	Paper Only
Other-Baseline Survey Somali	Formatted ConnectHome Baseline Survey-Somali Revised 8_4_16.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: 2,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,800	2,800
Annual IC Time Burden (Hours)	233	233
Annual IC Cost Burden (Dollars)	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.