Information Collection

Instrument 1. Success Sequence Screener

IC 251049 under ICR 202201-0970-003 · OMB 0970-0591.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 1. Success Sequence Screener (003) CLEAN_IOAS OS Appvd_CLEAN Jan 22.docx	Other-Survey
Instrument 1. Success Sequence Screener_final 4.22.22.docx	Other-Survey

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-Survey			Instrument 1. Success Sequence Screener_final 4.22.22.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: 675

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	675	675
Annual IC Time Burden (Hours)	56	56
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.