Information Collection

Baseline Survey of impact study participants

IC 223265 under ICR 201912-0990-001 · OMB 0990-0452.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0452 can be found here:

Documents and Forms

Document Name Document Type
Instrument 1_BaselineSurvey_revised_8.19.16.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Survey of impact study participants	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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
Instruction			Instrument 1_BaselineSurvey_revised_8.19.16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 865	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-865	865
Annual IC Time Burden (Hours)	-433	433
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.