Information Collection

Baseline Survey

IC 237094 under ICR 202003-0920-013 · OMB 0920-1284.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- Baseline Survey	Form and Instruction
0920- Baseline Survey Att 3c_Baseline Survey (1).docx	Form and Instruction

IC Title:

Baseline Survey

Agency IC Tracking Number:

0920-19BG

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 and Instruction	0920-	Baseline Survey	Att 3c_Baseline Survey (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

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	1,200	1,200
Annual IC Time Burden (Hours)	400	400
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.