Interview Respondent Info Form

NHE Demo Opioid Evaluation

Documents and Forms

Document Name Document Type
Interview Respondent Info Form.docx Other-Background Information Form
Interview Respondent Info Form.docx Interview Respondent Info Form IC Document

Information Collection (IC) Details

IC Title:	Interview Respondent Info Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Background Information Form			Interview Respondent Info Form.docx		No		Fillable Printable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Interview Respondent Info Form	Interview Respondent Info Form.docx	08/10/2020

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