Information Collection

Baseline Survey Web Mode

IC 228498 under ICR 201709-0920-009 · OMB 0920-1220.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-17HO Baseline Survey Web Mode	Form and Instruction
0920-17HO Att B-7. Falls Baseline Screenshots Att B-7. Falls Baseline Screenshots.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-17HO

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	0920-17HO	Att B-7. Falls Baseline Screenshots	Att B-7. Falls Baseline Screenshots.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 570

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	570	570
Annual IC Time Burden (Hours)	190	190
Annual IC Cost Burden (Dollars)	4,247	4,247

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.