Information Collection

Baseline Survey

IC 238160 under ICR 202108-0920-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Baseline Survey	Form and Instruction
Baseline survey Att. 1 - Baseline patient survey (1).docx	Form and Instruction
Baseline survey Att. 1 - Baseline patient survey (1).docx	Form and Instruction

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
Form and Instruction	none	Baseline survey	Att. 1 - Baseline patient survey (1).docx		Yes	Yes	Fillable Fileable

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
No associated records found

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