Information Collection

Home-based provider QUESTIONNAIRE WITH SCREENER (listed home-based providers)

IC 232741 under ICR 201905-0970-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (clean copy).docx	Other-Screener and Quesionnaire
4a_2019 NSECE Home-based Provider Screener and Questionnaire (clean)_051419.docx	Other-SUMMER Screener & Questionnair
4a_2019 NSECE Home-based Provider Screener and Questionnaire (tracking copy).docx Revised Home-based Provider Screener and Questionnaire - Tracked Version - Nonsub Change Req Dec 2018	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: Modified

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 (clean copy).docx		Yes	Yes	Fillable Fileable
Other-SUMMER Screener & Questionnaire			4a_2019 NSECE Home-based Provider Screener and Questionnaire (clean)_051419.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	Previously Approved
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
Revised Home-based Provider Screener and Questionnaire - Tracked Version - Nonsub Change Req Dec 2018	4a_2019 NSECE Home-based Provider Screener and Questionnaire (tracking copy).docx	12/06/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.