Information Collection

Client Check-in Questionnaire

IC 228976 under ICR 201812-0920-002 · OMB 0920-1218.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1218 can be found here:

Documents and Forms

Document Name Document Type
Client Check-in Questionnaire Form
Check-in Questionnaire - English Attachment 5 Client Check-In.docx Form
Client Check-in Questionnaire - Spanish Attachment 5 Client Check-In Form_spanish 17ACE_MAT.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Client Check-in Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	none	Check-in Questionnaire - English	Attachment 5 Client Check-In.docx		Yes	Yes	Fillable Fileable
Form	none	Client Check-in Questionnaire - Spanish	Attachment 5 Client Check-In Form_spanish 17ACE_MAT.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,187	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,374	2,374
Annual IC Time Burden (Hours)	594	594
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.