Baseline

CABHI Evaluation Client & Stakeholder Surveys

Documents and Forms

Document Name Document Type
Form Baseline Baseline Form and Instruction
Baseline Baseline Attachment 1. CABHI_Client Baseline Interview.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Baseline	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Baseline	Baseline	Attachment 1. CABHI_Client Baseline Interview.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,827	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,827	-58	5,885
Annual IC Time Burden (Hours)	2,447	505	1,942
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.