Information Collection

Baseline information form for participants (Attachment D)

IC 235592 under ICR 202105-0970-003 · OMB 0970-0537.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0537 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
BEES_NonSub Change Request_Attachment D-Generic BIF CLEAN_Nov-Dec 2020.docx	Other-Standard BIF
BEES_NonSub Change Request_Attachment D-Generic BIF CLEAN_Nov-Dec 2020.docx	Other-Standard BIF
Attachment D-1_BEES_BIF ARC_Clean.docx	Other-Tailored BIF - ARC Site
Attachment D-1_BEES_BIF ARC_Clean.docx	Other-Tailored BIF - ARC Site
Attachment D-2_BEES_BIF CCC_Clean.docx	Other-Tailored BIF - CCC Site
Attachment D-2_BEES_BIF CCC_Clean.docx	Other-Tailored BIF - CCC Site
Attachment D-3_BEES_BIF Franklin-Stark_Clean.docx	Other-Tailored BIF - Franklin-Stark
Attachment D-3_BEES_BIF Franklin-Stark_Clean.docx	Other-Tailored BIF - Franklin-Stark
Attachment D-4_BEES_BIF 2Gen-Chicago_Clean.docx	Other-Tailored BIF - 2Gen-Chicago Si
Attachment D-4_BEES_BIF 2Gen-Chicago_Clean.docx	Other-Tailored BIF - 2Gen-Chicago Si
Attachment D-5_BEES_BIF IPS FQHC_Clean.docx	Other-Tailored BIF - IPS FQHC site
Attachment D-5_BEES_BIF IPS FQHC_Clean.docx	Other-Tailored BIF - IPS FQHC site
Attachment D-1_BEES_IPS SUD BIF_May 2021_Clean.docx	Other-Tailored BIF - IPS SUD
Attachment D-1_BEES_IPS SUD BIF_May 2021_Clean.docx	Other-Tailored BIF - IPS SUD

IC Title:

Baseline information form for participants (Attachment D)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Standard BIF	BEES_NonSub Change Request_Attachment D-Generic BIF CLEAN_Nov-Dec 2020.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - ARC Site	Attachment D-1_BEES_BIF ARC_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - CCC Site	Attachment D-2_BEES_BIF CCC_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - Franklin-Stark Site	Attachment D-3_BEES_BIF Franklin-Stark_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - 2Gen-Chicago Site	Attachment D-4_BEES_BIF 2Gen-Chicago_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - IPS FQHC site	Attachment D-5_BEES_BIF IPS FQHC_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - IPS SUD	Attachment D-1_BEES_IPS SUD BIF_May 2021_Clean.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: 4,133

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,133	4,133
Annual IC Time Burden (Hours)	1,034	1,034
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.