Outcome Evaluation Baseline Survey

SMARTool Pilot Replication Project

Documents and Forms

Document Name Document Type
Form 3 Outcome Evaluation Baseline Survey Form and Instruction
3 Outcome Baseline Student Survey Appendix I. Baseline Student Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Outcome Evaluation Baseline Survey	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
Form and Instruction	3	Outcome Baseline Student Survey	Appendix I. Baseline Student Survey.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,596	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,596	1,596
Annual IC Time Burden (Hours)	798	798
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.