Information Collection

FSS Evaluation

IC 205698 under ICR 201707-2528-005 · OMB 2528-0296.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form XX-XXXX Informed Consent FSS Evaluation	Form
Form XX-XXXX Baseline Information Form-Head of Household FSS Evaluation	Form
Form Baseline Informati XX-XXXX FSS Evaluation	Form
Form XX-XXXX 36 Month Follow-up Survey FSS Evaluation	Form
Draft mini-survey questionnaire 2014-02-04_Updated.docx	Other-Draft mini-survey questionnair
XX-XXXX Informed Consent FSS EVALUATION OMB PACKET PART A - APPENDIX INFORMED CONSENT FORM.doc	Form
XX-XXXX Baseline Information Form-Head of Household FSS_A_4a_BIF_Household.docx	Form
Baseline Informati XX-XXXX FSS_A_4b_BIF_Adult.docx	Form
XX-XXXX 36 Month Follow-up Survey FSS NATIONAL EVALUATION 36 month survey draft_CLEAN_7.2016.docx	Form

IC Title:

FSS Evaluation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	XX-XXXX	Informed Consent	FSS EVALUATION OMB PACKET PART A - APPENDIX INFORMED CONSENT FORM.doc	No	Paper Only
Other-Draft mini-survey questionnaire			Draft mini-survey questionnaire 2014-02-04_Updated.docx	No	Paper Only
Form	XX-XXXX	Baseline Information Form-Head of Household	FSS_A_4a_BIF_Household.docx	No	Paper Only
Form	Baseline Information Form Adult	XX-XXXX	FSS_A_4b_BIF_Adult.docx	No	Paper Only
Form	XX-XXXX	36 Month Follow-up Survey	FSS NATIONAL EVALUATION 36 month survey draft_CLEAN_7.2016.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: 2,551

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2,551	2,551
Annual IC Time Burden (Hours)	-1,913	1,913
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.