Information Collection

Initial Questionnaire

IC 232275 under ICR 202005-2528-001 · OMB 2528-0321.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0321 can be found here:

Documents and Forms

Document Name Document Type
SSDE Supporting Statement Appendix A 06-20-18.docx Other-Initial Questionnaire for Trea
SSDE Supporting Statement Appendix B 06-20-18.docx Other-Initial Questionnaire for Acti

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Questionnaire	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
Other-Initial Questionnaire for Treatment Properties			SSDE Supporting Statement Appendix A 06-20-18.docx		No		Paper Only
Other-Initial Questionnaire for Active Control Properties with a Service Coordinator			SSDE Supporting Statement Appendix B 06-20-18.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-120	120
Annual IC Time Burden (Hours)	-180	180
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.