Information Collection

Baseline Interview

IC 217703 under ICR 201609-0920-002 · OMB 0920-1005.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Baseline Interview	Form and Instruction
Baseline Interview Attach D1 Screener Interviewer guide_1005 OlderAdult_Ext_ICRO_9216.docx	Form and Instruction

IC Title:

Baseline Interview

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	none	Baseline Interview	Attach D1 Screener Interviewer guide_1005 OlderAdult_Ext_ICRO_9216.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42484

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	-500	1,000
Annual IC Time Burden (Hours)	83	-84	167
Annual IC Cost Burden (Dollars)	0	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.