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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.