Tailored Services Practice Model Survey

Center for States Evaluation Ancillary Data Collection

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0501 can be found here:

Documents and Forms

Document Name Document Type
TAB H_Tailored Services Practice Model Survey.docx Other-Model Survey

Information Collection (IC) Details

IC Title:	Tailored Services Practice Model Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-Model Survey			TAB H_Tailored Services Practice Model Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 130	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	130	-70	200
Annual IC Time Burden (Hours)	16	-8	24
Annual IC Cost Burden (Dollars)	0	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.