Information Collection

Client Questionnaire - baseline

IC 228977 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⚠️ Notice: This information collection may be referencing outdated material.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 Questionnaire - baseline	Form
Client questionnaire - baseline - Spanish Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx	Form
Client questionnaire - baseline English Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx	Form

IC Title:

Client Questionnaire - baseline

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	Client questionnaire - baseline - Spanish	Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx		Yes	Yes	Fillable Fileable
Form	none	Client questionnaire - baseline English	Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 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	1,187	1,187
Annual IC Time Burden (Hours)	1,029	1,029
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.