Information Collection

Home-based provider QUESTIONNAIRE WITH SCREENER (listed home-based providers)

IC 232741 under ICR 201808-0970-002 · OMB 0970-0391.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0391 can be found here:

Documents and Forms

Document Name Document Type
4a_2019 NSECE Home-based Provider Screener and Questionnaire.docx Other-Screener and Quesionnaire
4b_2019 NSECE Home-based Provider Screener and Questionnaire_Spanish.docx Home Based Provider Screener and Questionnaire SPANISH IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Home-based provider QUESTIONNAIRE WITH SCREENER (listed home-based providers)	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-Screener and Quesionnaire			4a_2019 NSECE Home-based Provider Screener and Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,680	2,680
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Home Based Provider Screener and Questionnaire SPANISH	4b_2019 NSECE Home-based Provider Screener and Questionnaire_Spanish.docx	08/20/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.