Information Collection

Head Of Household Family Interview Consent Form

IC 249826 under ICR 202101-2528-005 · OMB 2528-0337.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0337 can be found here:

Documents and Forms

Document Name Document Type
Final - Attachment H Head of Household Family Interview Consent Form.docx Other-HEAD OF HOUSEHOLD FAMILY INTER

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HEAD OF HOUSEHOLD FAMILY INTERVIEW CONSENT FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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-HEAD OF HOUSEHOLD FAMILY INTERVIEW CONSENT FORM			Final - Attachment H Head of Household Family Interview Consent Form.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: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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