Information Collection

Assessment and Service Delivery State Lead Interviews-Supplemental Questions

IC 226794 under ICR 201705-0970-004 · OMB 0970-0501.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0501 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Assessment and Service Delivery State Lead Interviews-Supplemental Questions	Form and Instruction
1 Assessment and Service Delivery State Lead Interview Assessment and Service Delivery State Lead Interview - Supplemental Questions 021017.docx	Form and Instruction

IC Title:

Assessment and Service Delivery State Lead Interviews-Supplemental Questions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	Assessment and Service Delivery State Lead Interview	Assessment and Service Delivery State Lead Interview - Supplemental Questions 021017.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
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.