Information Collection

ConnectHome Baseline Survey

IC 218649 under ICR 201608-2528-001 · OMB 2528-0308.

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

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.