Information Collection

Baseline Survey

IC 238160 under ICR 202004-0920-007 · OMB 0920-1281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1281 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att B3 Baseline Survey Screenshots final.pdf Baseline Survey Screenshots	IC Document

IC Title:

Baseline Survey

Agency IC Tracking Number:

0920-19ARD

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

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Baseline Survey Screenshots	Att B3 Baseline Survey Screenshots final.pdf	10/16/2019

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