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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.