Information Collection

Baseline

IC 195854 under ICR 201705-0930-002 · OMB 0930-0320.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Baseline Baseline	Form and Instruction
Baseline Baseline Attachment 1. CABHI_Client Baseline Interview.doc	Form and Instruction

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:

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	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 %

table that charts list of burden
	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

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.