Information Collection

Mentee Pre-Assessment

IC 229862 under ICR 201710-0990-002 · OMB 0990-0463.

Documents and Forms

Document Name Document Type
ICDI Mentee Pre-Assessment Form_Clean.docx Other-PRE-ASSESSMENT

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Mentee Pre-Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-PRE-ASSESSMENT			ICDI Mentee Pre-Assessment Form_Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	233	233
Annual IC Cost Burden (Dollars)	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.